Dual Relationship DB

You have 2 Discussion Question options this week – please pick one and answer it in a minimum of 175 words:

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Option 1:

The majority of chapter 1 discusses the topic of dual or multiple relationships between a professional and a person seeking his/her help. Define the term “Dual Relationship” in your own words.

Option 2:

According to Chapter 4, “Counselor self-disclosure has been an issue of ethical concern as a result of

research such as that conducted by R. I. Simon (1991), who found that inappropriate self-disclosure is the type of boundary violation that is most likely to precede sexual intimacies. Nonetheless, Neukrug and Milliken (2011) found that nearly 87% of surveyed counselors rated self-disclosing to a

client as “ethical.” Self-disclosure may be therapeutically beneficial or harmful, depending on a number of factors.” Discuss how self-disclosure can be both beneficial and harmful.

Chapter 1
Boundary Issues in Perspective

Dual or multiple relationships occur when a professional assumes two or more roles simultaneously or sequentially with a person seeking his or her help. This may involve taking on more than one professional role (such as counselor and teacher) or combining professional and nonprofessional roles (such as counselor and friend or counselor and lover). Another way of stating this is that a helping professional enters into a dual or multiple relationship whenever the professional has another, significantly different relationship with a client, a student, or a supervisee.

Multiple relationship issues exist throughout our profession and affect virtually all counselors, regardless of their work setting or the client populations they serve. Relationship boundary issues have an impact on the work of helping professionals in diverse roles, including counselor educator, supervisor, agency counselor, private practitioner, school counselor, college or university student personnel specialist, rehabilitation counselor, and practitioner in other specialty areas. These issues affect the dyadic relationship between counselor and client, and they can also emerge in complex ways in tripartite relationships (such as client/supervisee/supervisor or client/consultee/consultant) and in family therapy and group work. No professional remains untouched by the potential difficulties inherent in dual or multiple relationships.

This book is a revision of our earlier editions, Dual Relationships in Counseling (Herlihy & Corey, 1992) and Boundary Issues in Counseling: Multiple Roles and Responsibilities (Herlihy & Corey, 1997, 2006b), but with an expanded focus. Since we last wrote together about this topic, helping professionals have continued to debate issues of multiple relationships, roles, and responsibilities; power; and boundaries in counseling.

Because of the complexities involved, the term multiple relationship is often more descriptive than dual relationship. Dual or multiple relationships occur when mental health practitioners interact with clients in more than one relationship, whether professional, social, or business. In the most recent versions of the ACA Code of Ethics (American Counseling Association [ACA], 2005, 2014), both of these terms have been replaced with the term nonprofessional interactions to indicate those additional relationships other than sexual or romantic ones. In this book, we continue to use the terms dual or multiple relationships to describe these nonprofessional relationships as well as dual professional relationships.

This revised edition is based on the assumption that counseling professionals must learn how to manage multiple roles and responsibilities (or nonprofessional interactions or relationships) effectively rather than learn how to avoid them. This entails managing the power differential inherent in counseling or training relationships, balancing boundary issues, addressing nonprofessional relationships, and striving to avoid using power in ways that might cause harm to clients, students, or supervisees. This book rests on the premise that we can develop ethical decision-making skills that will enable us to weigh the pros and cons of multiple roles and nonprofessional interactions or relationships.

Beginning in the 1980s, the counseling profession became increasingly concerned with the ethical issues inherent in entering into multiple relationships and establishing appropriate boundaries. Much has been written since then about the harm that results when counseling professionals enter into sexual relationships with their clients. Throughout the 1980s, sexual misconduct received a great deal of attention in the professional literature, and the dangers of sexual relationships between counselor and client, professor and student, and supervisor and supervisee have been well documented. Today there is clear and unanimous agreement that sexual relationships with clients, students, and supervisees are unethical, and prohibitions against them have been translated into ethics codes and law. Even those who have argued most forcefully against dual relationship prohibitions (e.g., Lazarus & Zur, 2002; Zur, 2007) agree that sexual dual relationships are never acceptable. We examine the issue of sexual dual relationships in detail in

Chapter 2

In the 1990s and until the turn of the century, nonsexual dual and multiple relationships received considerable attention in professional journals and counseling textbooks. The codes of ethics of the ACA 2014), the American School Counselor Association (ASCA; 2010), the American Psychological Association (APA; 2010), the National Association of Social Workers (NASW; 2008), and the American Association for Marriage and Family Therapy (AAMFT; 2012) have all dealt specifically and extensively with topics such as appropriate boundaries, recognizing potential conflicts of interest, and ethical means for dealing with dual or multiple relationships. Since this book was last revised in 2006, new articles on these topics have slowed to a trickle in the professional literature. There has been an increasing recognition and acceptance that dual or multiple relationships are often complex, which means that few simple and absolute answers can neatly resolve ethical dilemmas that arise. It is not always possible for counselors to play a singular role in their work, nor is this always desirable. From time to time we all will wrestle with how to balance multiple roles in our professional and nonprofessional relationships. Examples of problematic concerns associated with dual relationships include whether to barter with a client for goods or services, whether it is ever acceptable to counsel a friend of a friend or social acquaintance, whether to interact with clients outside the office, how a counselor educator might manage dual roles as educator and therapeutic agent with students, how to ethically conduct experiential groups as part of a group counseling course, and whether it is acceptable to develop social relationships with a former client.

In this chapter, we focus on nonsexual dual relationships that can arise in all settings. One of our guest contributors, Arnold Lazarus, makes a case for the potential benefits of transcending boundaries. He takes the position that benefits can accrue when therapists are willing to think and venture outside the proverbial box. The following questions will guide our discussion:

· What guidance do our codes of ethics offer about dual or multiple nonprofessional relationships?

· What makes dual or multiple relationships problematic?

· What factors create the potential for harm?

· What are the risks (and benefits) inherent in dual or multiple relationships, for all parties involved?

· What important but subtle distinctions should be considered?

· What safeguards can be built in to minimize risks?

Ethical Standards

The codes of ethics of all the major associations of mental health professionals address the issue of multiple relationships. To begin our discussion, consider these excerpts from the codes of ethics for mental health counselors, marriage and family therapists, social workers, school counselors, and psychologists.

The ACA Code of Ethics (ACA, 2014) provides several guidelines regarding nonprofessional interactions. Counselors are advised that:

Sexual and/or Romantic Relationships Prohibited

Sexual and/or romantic counselor–client interactions or relationships with current clients, their romantic partners, or their family members are prohibited. This prohibition applies to both in-person and electronic interactions or relationships. (Standard A.5.a.)

Previous Relationships

Counselors consider the risks and benefits of accepting as clients those with whom they have had a previous relationship. These potential clients may include individuals with whom the counselor has had a casual, distant, or past relationship. Examples include mutual or past membership in a professional association, organization, or community. When counselors accept these clients, they take appropriate professional precautions such as informed consent, consultation, supervision, and documentation to ensure that judgment is not impaired and no exploitation occurs. (Standard A.6.a.)

Extending Counseling Boundaries

Counselors consider the risks and benefits of extending current counseling relationships beyond conventional parameters. Examples include attending a client’s formal ceremony (e.g., a wedding/commitment ceremony or graduation), purchasing a service or product provided by a client (excepting unrestricted bartering), and visiting a client’s ill family member in the hospital. In extending these boundaries, counselors take appropriate professional precautions such as informed consent, consultation, supervision, and documentation to ensure that judgment is not impaired and no harm occurs. (Standard A.6.b.)

Documenting Boundary Extensions

If counselors extend boundaries as described in A.6.a. and A.6.b., they must officially document, prior to the interaction (when feasible), the rationale for such an interaction, the potential benefit, and anticipated consequences for the client or former client and other individuals significantly involved with the client or former client. When unintentional harm occurs to the client or former client, or to an individual significantly involved with the client or former client, the counselor must show evidence of an attempt to remedy such harm. (Standard A.6.c.)

The standard of the AAMFT Code of Ethics (AAMFT, 2012) dealing with dual relationships advises therapists to avoid such relationships due to the risk of exploitation:

Marriage and family therapists are aware of their influential position with respect to clients, and they avoid exploiting the trust and dependency of such persons. Therapists, therefore, make every effort to avoid conditions and multiple relationships with clients that could impair professional judgment or increase the risk of exploitation. Such relationships include, but are not limited to, business or close personal relationships with a client or the client’s immediate family. When the risk of impairment or exploitation exists due to conditions or multiple roles, therapists document the appropriate precautions taken. (1.3.)

The NASW (2008) code of ethics, using language similar to that of the AAMFT, focuses on the risk of exploitation or potential harm to clients:

Social workers should not engage in dual or multiple relationships with clients or former clients in which there is a risk of exploitation or potential harm to the client. In instances when dual or multiple relationships are unavoidable, social workers should take steps to protect clients and are responsible for setting clear, appropriate, and culturally sensitive boundaries. (Dual or multiple relationships occur when social workers relate to clients in more than one relationship, whether professional, social, or business. Dual or multiple relationships can occur simultaneously or consecutively.) (

1.0

6.c.)

The Ethical Standards for School Counselors (ASCA, 2010) also advises that school counselors avoid dual relationships that carry a potential risk of harm and, like the ACA, suggests safeguards. The school counselors’ code is the only one, among those reviewed here, that addresses the burgeoning usage of social media and its potential for creating inappropriate relationships between students and professionals.

Professional school counselors:

Avoid dual relationships that might impair their objectivity and increase the risk of harm to the student (e.g., counseling one’s family members, close friends or associates). If a dual relationship is unavoidable, the school counselor is responsible for taking action to eliminate or reduce the potential for harm to the student through the use of safeguards, which might include informed consent, consultation, supervision and documentation. (A.4.a.)

Maintain appropriate professional distance with students at all times. (A.4.b.)

Avoid dual relationships with students through communication mediums such as social networking sites. (A.4.c.)

The APA (2010) code addresses multiple relationships quite extensively:

(a) A multiple relationship occurs when a psychologist is in a professional role with a person and (1) at the same time is in another role with the same person, (2) at the same time is in a relationship with a person closely associated with or related to the person with whom the psychologist has the professional relationship, or (3) promises to enter into another relationship in the future with the person or a person closely associated with or related to the person.

A psychologist refrains from entering into a multiple relationship if the multiple relationship could reasonably be expected to impair the psychologist’s objectivity, competence, or effectiveness in performing his or her functions as a psychologist, or otherwise risks exploitation or harm to the person with whom the professional relationship exists.

Multiple relationships that would not reasonably be expected to cause impairment or risk exploitation or harm are not unethical.

(b) If a psychologist finds that, due to unforeseen factors, a potentially harmful multiple relationship has arisen, the psychologist takes reasonable steps to resolve it with due regard for the best interests of the affected person and maximal compliance with the Ethics Code.

(c) When psychologists are required by law, institutional policy, or extraordinary circumstances to serve in more than one role in judicial or administrative proceedings, at the outset they clarify role expectations and the extent of confidentiality and thereafter as changes occur. (3.05.)

As can be seen, the ethics codes for mental health professionals all take considerable care to address dual and multiple relationships. Ethical problems often arise when clinicians blend their professional relationships with other kinds of relationships with a client. The ethics codes of most professional organizations currently warn against crossing these boundaries when it is not in the best interests of the client. The emphasis is no longer on an outright prohibition of dual or multiple relationships; rather, the focus has shifted to avoiding the misuse of power and exploitation of the client. Also, it is increasingly acknowledged that some nonprofessional relationships are potentially beneficial.

What Makes Dual or Multiple Relationships So Problematic?

Dual and multiple relationships are fraught with complexities and ambiguities that require counselors to make judgment calls and apply the codes of ethics carefully to specific situations. These relationships are problematic for a number of reasons:

· They can be difficult to recognize.

· They can be very harmful; but they are not always harmful, and some have argued that they can be beneficial.

· They are the subject of conflicting views.

· They are not always avoidable.

Dual or Multiple Relationships Can Be Difficult to Recognize

Dual or multiple relationships can evolve in subtle ways. Some counselors, counselor educators, or supervisors may somewhat innocently establish a form of nonprofessional relationship. They may go on a group outing with clients, students, or supervisees. A counselor may agree to play tennis with a client, go on a hike or a bike ride, or go jogging together when they meet by accident at the jogging trail. Initially, this nonprofessional interaction may seem to enhance the trust needed to establish a good working relationship in therapy. However, if such events continue to occur, eventually a client may want more nonprofessional interactions with the therapist. The client may want to become close friends with the counselor and feel let down when the counselor declines an invitation to a social event. If a friendship does begin to develop, the client may become cautious about what he or she reveals in counseling for fear of negatively affecting the friendship. At the same time, the counselor may avoid challenging the client out of reluctance to offend someone who has become a friend.

It can be particularly difficult to recognize potential problems when dual relationships are sequential rather than simultaneous. A host of questions present themselves: Can a former client eventually become a friend? How does the relationship between supervisor and supervisee evolve into a collegial relationship after the formal supervision is completed? What kinds of posttherapy relationships are ever acceptable? These questions are explored in later chapters.

Dual or Multiple Relationships Are Not Always Harmful, and They May Be Beneficial

A wide range of outcomes to dual or multiple relationships is possible, from harmful to beneficial. Some dual relationships are clearly exploitive and do serious harm to the client and to the professional involved. Others are benign; that is, no harm is done. In some instances, dual relating may strengthen the therapeutic relationship. Moleski and Kiselica (2005) provide a review of the literature regarding the nature, scope, and complexity of dual relationships ranging from the destructive to the therapeutic. They suggest that counselors who begin a dual relationship are not always destined for disaster. They describe some therapeutic dual relationships that complement and enhance the counseling relationship. For example, in counseling clients from diverse cultures, practitioners may find it necessary to engage in boundary crossings to establish the counseling relationship. Moleski and Kiselica maintain that the positive or negative value of the secondary relationship is determined by the degree to which it enhances the primary counseling relationship. Therapeutic dual relationships are characterized by the counselor’s commitment to doing what is in the best interest of the client.

Consider the following two examples. The first is a harmful dual relationship; the second could be described as benign or even therapeutic.

· A high school counselor enters into a sexual relationship with a 15-year-old student client.

· All professionals agree that this relationship is exploitive in the extreme. The roles of counselor and lover are never compatible, and the seriousness of the violation is greatly compounded by the fact that the client is a minor.

· A couple plans to renew their wedding vows and host a reception after the ceremony. The couple invites their counselor, who attends the ceremony, briefly appears at the reception to offer her best wishes to the couple, and leaves. The couple is pleased that the counselor came, especially because they credit the counseling process with helping to strengthen their marriage.

· Apparently, no harm has been done. In this case the counselor’s blending of a nonprofessional role with her professional role could be argued to be benign or even beneficial to the counseling relationship.

Dual and Multiple Relationships Are the Subject of Conflicting Views

The topic of dual and multiple relationships has been hotly debated in the professional literature. A few writers argue for the potential benefits of nonsexual dual relationships, or nonprofessional relationships. Zur (2007) asserts that boundary crossings are not unethical and that they often embody the most caring, humane, and effective interventions. Other writers take a cautionary stance, focusing on the problems inherent in dual or multiple relationships and favoring a strict interpretation of ethical standards aimed at regulating professional boundaries. Persuasive arguments have been made for both points of view.

Welfel (2013) points out that many ethics scholars take a stronger stance against multiple relationships than that found in codes of ethics, especially those in which one role is therapeutic. Perhaps this is because their study of the issues has made them more keenly aware of the risks. Through their work on ethics committees, licensure boards, or as expert witnesses in court cases, they may have direct knowledge of harm that has occurred.

Even when practitioners have good intentions, they may unconsciously exploit or harm clients who are vulnerable in the relationship. If the professional boundaries become blurred, there is a strong possibility that confusion, disappointment, and disillusionment will result for both parties. For these reasons, some writers caution against entering into more than one role with a client because of the potential problems involved. They advise that it is generally a good idea to avoid multiple roles unless there is sound clinical justification for considering multiple roles.

Although dual relationships are not damaging to clients in all cases, St. Germaine (1993) believes counselors must be aware that the potential for harm is always present. She states that errors in judgment often occur when the counselor’s own interests become part of the equation. This loss of objectivity is one factor that increases the risk of harm.

Gabbard (1994) and Gutheil and Gabbard (1993) have warned of the dangers of the slippery slope. They caution that when counselors make one exception to their customary boundaries with clients, it becomes easier and easier to make more exceptions until an exception is made that causes harm. They argue that certain actions can lead to a progressive deterioration of ethical behavior. Furthermore, if professionals do not adhere to uncompromising standards, their behavior may foster relationships that are harmful to clients. Remley and Herlihy (2014) summarize this argument by stating, “The gradual erosion of the boundaries of the professional relationship can take counselors down an insidious path” (p. 206) that could even lead, ultimately, to a sexual relationship with a client.

Other writers are critical of this notion of the slippery slope, stating that it tends to result in therapists practicing in an overly cautious manner that may harm clients (Lazarus & Zur, 2002; Pope & Vasquez, 2011; Speight, 2012; Zur, 2007). Overlapping boundaries and crossing boundaries are not necessarily problematic; instead, they can be positive and beneficial within therapeutic relationships (Speight, 2012). G. Corey, Corey, Corey, and Callanan (2015) remind us that ethics codes are creations of humans, not divine decrees that contain universal truth. They do not believe dual or multiple relationships are always unethical, and they have challenged counselors to reflect honestly and think critically about the issues involved. They believe codes of ethics should be viewed as guidelines to practice rather than as rigid prescriptions and that professional judgment must play a crucial role.

Tomm (1993) has suggested that maintaining interpersonal distance focuses on the power differential and promotes an objectification of the therapeutic relationship. He suggested that dual relating invites greater authenticity and congruence from counselors and that counselors’ judgments may be improved rather than impaired by dual relationships, making it more difficult to use manipulation and deception or to hide behind the protection of a professional role.

Lazarus and Zur (2002) and Zur (2014) make the point that none of the codes of ethics of any of the various professions takes the position that nonsexual dual relationships are unethical per se. They believe that “dual relationships are neither always unethical nor do they necessarily lead to harm and exploitation, nor are they always avoidable. Dual relationships can be helpful and beneficial to clients if implemented intelligently, thoughtfully, and with integrity and care” (Lazarus & Zur, 2002, p. 472). They remind counselors that dual relationships are not, in and of themselves, illegal, unethical, unprofessional, or inappropriate. Instead, unethical dual relationships are those that are reasonably likely to exploit clients or impair professional judgment.

We agree that duality itself is not unethical; rather, the core of the problem lies in the potential for the counselor to exploit clients or misuse power. Simply avoiding multiple relationships does not prevent exploitation. Counselors might deceive themselves into thinking that they cannot possibly exploit their clients if they avoid occupying more than one professional role. In reality, counselors can misuse their therapeutic power and influence in many ways and can exploit clients without engaging in dual or multiple relationships.

Some Dual or Multiple Relationships Are Unavoidable

It seems evident from the controversy over dual or multiple relationships that not all dual relationships can be avoided and that not all of these relationships are necessarily harmful or unethical. The APA (2010) states that “multiple relationships that would not reasonably be expected to cause impairment or risk exploitation or harm are not unethical” (3.05.a.). The key is to take steps to ensure that the practitioner’s judgment is not impaired and that no exploitation or harm to the client occurs.

Perhaps some of the clearest examples of situations in which dual relationships may be unavoidable occur in the lives of rural practitioners. In an isolated, rural community the local minister, merchant, banker, beautician, pharmacist, or mechanic might be clients of a particular counselor. In such a setting, the counselor may have to play several roles and is likely to find it more difficult to maintain clear boundaries than it is for colleagues who practice in more densely populated areas. It is worth noting that “small worlds” can exist in urban as well as in rural environments. In many close-knit communities, nonprofessional contacts and relationships are likely to occur because clients often seek out counselors who share their values and are familiar with their culture. These “small worlds” might include religious congregations, those in recovery from substance abuse, the gay/lesbian/bisexual/transgender community, some racial or ethnic minority groups, and the military.

The debate over dual or multiple relationships has been extensive, and much of it has been enlightening and thought provoking. At this point, we ask you to consider where you stand.

· What is your stance toward dual or multiple relationships?

· With which of the perspectives do you most agree?

· How did you arrive at this stance?

· What do you see as its risks and benefits?

Boundary Crossings Versus Boundary Violations

Some behaviors in which professionals may engage from time to time have a potential for creating a problematic situation, but these behaviors are not, by themselves, dual relationships. Some examples might be accepting a small gift from a client, accepting a client’s invitation to a special event such as a wedding, going out for coffee or tea with a client, making home visits to clients who are ill, or hugging a client at the end of a particularly painful session. Similar types of interactions are listed in the ACA Code of Ethics (ACA, 2014) as examples of “extending counseling boundaries” (Standard A.6.b.)

Some writers (Gabbard, 1995; Gutheil & Gabbard, 1993; R. I. Simon, 1992; Smith & Fitzpatrick, 1995) have suggested that such interactions might be considered boundary crossings rather than boundary violations. A boundary violation is a serious breach that results in exploitation or harm to clients. In contrast, a boundary crossing is a departure from commonly accepted practice that might benefit the client. Crossings occur when the boundary is shifted to respond to the needs of a particular client at a particular moment. Boundary crossings may even result in clinically effective interventions (Zur, 2012).

Interpersonal boundaries are not static and may be redefined over time as counselors and clients work closely together. Zur and Lazarus (2002) take the position that rigid boundaries are not in the best interests of clients. They maintain that rigidity, distance, and aloofness are in direct conflict with doing what is therapeutically helpful for clients. We agree with Zur and Lazarus’s thoughts on rigid boundaries, but we also believe that even seemingly innocent behaviors can lead to dual relationship entanglements with the potential for exploitation and harm if they become part of a pattern of blurring professional boundaries.

Some roles that professionals play involve an inherent duality. One such role is that of supervisor. Supervisees often experience an emergence of earlier psychological wounds and discover some of their own unfinished business as they become involved in working with clients. Ethical supervisors do not abandon their supervisory responsibilities by becoming counselors to supervisees, but they can encourage their supervisees to view personal therapy with another professional as a way to become more effective as a counselor and as a person. At the same time, although the supervisor and therapist roles differ, personal issues arise in both relationships, and supervisors need to give careful thought as to when and how these issues should be addressed. As another example, counselor educators serve as teachers, as therapeutic agents for student growth and self-awareness, as supervisors, and as evaluators, either sequentially or simultaneously. This role blending can present ethical dilemmas involving conflicts of interest or impaired judgments.

None of these roles or behaviors actually constitutes an ongoing dual relationship of the type that is likely to lead to sanctions by an ethics committee. Nonetheless, each does involve two individuals whose power positions are not equal. Role blending is not necessarily unethical, but it does require vigilance on the part of the professional to ensure that no exploitation occurs. One of the major difficulties in dealing with dual relationship issues is the lack of clear-cut boundaries between roles. Where exactly is the boundary between a counseling relationship and a friendship? How does a counselor educator remain sensitive to the need to promote student self-understanding without inappropriately acquiring personal knowledge about the student? Can a supervisor work effectively without addressing the supervisee’s personal concerns that may be impeding the supervisee’s performance? These are difficult questions, and any answers must include a consideration of the potential harm to clients, students, or supervisees when a dual relationship is initiated.

The Potential for Harm

Whatever the outcome of a dual or multiple relationship, a potential for harm almost always exists from the beginning of the relationship. To illustrate, let’s revisit the example given earlier of a behavior that was identified as benign or even therapeutic. No apparent harm was done when the marriage counselor attended the renewal of wedding vows ceremony and reception. But what might have happened if the counselor had simply accepted the invitation without discussing with the couple any potential problems that might arise? What if the counselor had been approached at the reception and asked how she knew the couple? Had the counselor answered honestly, she would have violated the privacy of the professional relationship. Had she lied or given an evasive answer, harm to the clients would have been avoided, but the counselor could hardly have felt good about herself as an honest and ethical person.

One of the major problems with multiple relationships is the possibility of exploiting the client (or student or supervisee). Kitchener and Harding (1990) contend that dual relationships lie along a continuum from those that are potentially very harmful to those with little potential for harm. They concluded that dual relationships should be entered into only when the risks of harm are small and when there are strong, offsetting ethical benefits for the client.

How does one assess the potential for harm? Kitchener and Harding identified three factors that counselors should consider: incompatibility of expectations on the part of the client, divergence of responsibilities for the counselor, and the power differential between the parties involved.

First, the greater the incompatibility of expectations in a dual role, the greater the risk of harm. For example, John, a supervisor, is also providing personal counseling to Suzanne, his supervisee. Although Suzanne understands that evaluation is part of the supervisory relationship, she places high value on the confidentiality of the counseling relationship. John is aware that her personal problems are impeding her performance as a counselor. In his supervisory role, he is expected to serve not only Suzanne’s interests but also those of the agency in which she is employed and of the public that she will eventually serve. When he shares his evaluations with her employer as his supervisory contract requires, and notes his reservations about her performance (without revealing the specific nature of her personal concerns), Suzanne feels hurt and betrayed. The supervisory behaviors to which she had agreed when she entered into supervision with John were in conflict with the expectations of confidentiality and acceptance that she had come to hold for John as her counselor.

Second, as the responsibilities associated with dual roles diverge, the potential for divided loyalties and loss of objectivity increases. When counselors also have personal, political, social, or business relationships with their clients, their self-interest may be involved and may compromise the client’s best interest. For example, Lynn is a counselor in private practice who has entered into a counseling relationship with Paula, even though she and Paula are partners in a small, part-time mail order business. In the counseling relationship, Paula reveals that she is considering returning to college, which means that she will have to give up her role in the business. Lynn is faced with divided loyalties because she does not want the business to fold and she does not have the time to take it over. As this example illustrates, it is difficult to put the client’s needs first when the counselor is also invested in meeting her own needs.

The third factor has to do with influence, power, and prestige. Clients, by virtue of their need for help, are in a dependent, less powerful, and more vulnerable position. For example, Darla is a counselor educator who is also counseling Joseph, a graduate student in the program. When a faculty committee meets to assess Joseph’s progress, Joseph is given probationary status because his work is marginal. Although Darla assures Joseph that she revealed nothing about his personal problems during the committee meeting, Joseph’s trust is destroyed. He is fearful of revealing his personal concerns in counseling with Darla because he knows that Darla will be involved in determining whether he will be allowed to continue his graduate studies at the end of his probationary period. He wants to switch to another counselor but is afraid of offending Darla. Counselor educators and counselors must be sensitive to the power and authority associated with their roles. They must resist using their power to manipulate students or clients. Because of the power differential, it is the professional’s responsibility to ensure that the more vulnerable individual in the relationship is not harmed.

Risks in Dual or Multiple Relationships

The potential for harm can translate into risks to all parties involved in a dual relationship. These risks can even extend to others not directly involved in the relationship.

Risks to Consumers

Of primary concern is the risk of harm to the consumer of counseling services. Clients who believe that they have been exploited in a dual relationship are bound to feel confused, hurt, and betrayed. This erosion of trust may have lasting consequences. These clients may be reluctant to seek help from other professionals in the future. Clients may be angry about being exploited but feel trapped in a dependence on the continuing relationship. Some clients, not clearly understanding the complex dynamics of a dual relationship, may feel guilty and wonder, “What did I do wrong?” Feelings of guilt and suppressed anger are potential outcomes when there is a power differential.

Students or supervisees, in particular, may be aware of the inappropriateness of their dual relationships yet feel that the risks are unacceptably high in confronting a professional who is also their professor or supervisor. Any of these feelings—hurt, confusion, betrayal, guilt, anger—if left unresolved could lead to depression and helplessness, the antitheses of desired counseling outcomes.

Risks to the Professional

Risks to the professional who becomes involved in a dual relationship include damage to the therapeutic relationship and, if the relationship comes to light, loss of professional credibility, charges of violations of ethical standards, suspension or revocation of license or certification, and risk of malpractice litigation. Malpractice actions against therapists are a risk when dual relationships have caused harm to the client, and the chances of such a suit being successful increase if the therapist cannot provide sound clinical justification and demonstrate that such practices are within an accepted standard of care.

Many dual or multiple relationships go undetected or unreported and never become the subject of an inquiry by an ethics committee, licensure board, or court. Nonetheless, these relationships do have an effect on the professionals involved, causing them to question their competence and diminishing their sense of moral self-hood.

Effects on Other Consumers

Dual or multiple relationships can create a ripple effect, affecting even those who are not directly involved in the relationship. This is particularly true in college counseling centers, schools, hospitals, counselor education programs, or any other relatively closed system in which other clients or students have opportunities to be aware of a dual relationship. Other clients might well resent that one client has been singled out for a special relationship. This same consideration is true in dual relationships with students and supervisees. Because a power differential is also built into the system, this resentment may be coupled with a reluctance to question the dual relationship openly for fear of reprisal. Even independent private practitioners can be subject to the ripple effect. Former clients are typically a major source of referrals. A client who has been involved in a dual relationship and who leaves that relationship feeling confused, hurt, or betrayed is not likely to recommend the counselor to friends, relatives, or colleagues.

Effects on Other Professionals

Fellow professionals who are aware of a dual or multiple relationship are placed in a difficult position. Confronting a colleague is always uncomfortable, but it is equally uncomfortable to condone the behavior through silence. This creates a distressing dilemma that can undermine the morale of any agency, center, hospital, or other system in which it occurs. Paraprofessionals or others who work in the system and who are less familiar with professional codes of ethics may be misled and develop an unfortunate impression regarding the standards of the profession.

Effects on the Profession and Society

The counseling profession itself is damaged by the unethical conduct of its members. As professionals, we have an obligation both to avoid causing harm in dual relationships and to act to prevent others from doing harm. If we fail to assume these responsibilities, our professional credibility is eroded, regulatory agencies will intervene, potential clients will be reluctant to seek counseling assistance, and fewer competent and ethical individuals will enter counselor training programs. Conscientious professionals need to remain aware not only of the potential harm to consumers but also of the ripple effect that extends the potential for harm.

Safeguards to Minimize Risks

Whenever we as professionals are operating in more than one role, and when there is potential for negative consequences, it is our responsibility to develop safeguards and measures to reduce (if not eliminate) the potential for harm. These guidelines include the following:

· Set healthy boundaries from the outset. It is a good idea for counselors to have in their professional disclosure statements or informed consent documents a description of their policy pertaining to professional versus personal, social, or business relationships. This written statement can serve as a springboard for discussion and clarification.

· Involve the client in setting the boundaries of the professional or nonprofessional relationship. Although the ultimate responsibility for avoiding problematic dual relationships rests with the professional, clients can be active partners in discussing and clarifying the nature of the relationship. It is helpful to discuss with clients what you expect of them and what they might expect of you.

· Informed consent needs to occur at the beginning of and throughout the relationship. If potential dual relationship problems arise during the counseling relationship, these should be discussed in a frank and open manner. Clients have a right to be informed about any possible risks.

· Practitioners who are involved in unavoidable dual relationships or nonprofessional relationships need to keep in mind that, despite informed consent and discussion of potential risks at the outset, unforeseen problems and conflicts can arise. Discussion and clarification may need to be an ongoing process.

· Consultation with fellow professionals can be useful in getting an objective perspective and identifying unanticipated difficulties. We encourage periodic consultation as a routine practice for professionals who are engaged in dual relationships. We also want to emphasize the importance of consulting with colleagues who hold divergent views, not just those who tend to support our own perspectives.

· When dual or multiple relationships are particularly problematic, or when the risk for harm is high, practitioners are advised to work under supervision.

· Counselor educators and supervisors can talk with students and supervisees about balance of power issues, boundary concerns, appropriate limits, purposes of the relationship, potential for abusing power, and subtle ways that harm can result from engaging in different and sometimes conflicting roles.

· Professionals are wise to document any dual relationships in their clinical case notes, more as a legal than as an ethical precaution. In particular, it is a good idea to keep a record of any actions taken to minimize the risk of harm.

· If necessary, refer the client to another professional.

Some Gray Areas

Although the ACA Code of Ethics (ACA, 2014) expressly forbids sexual or romantic relationships with clients or former clients, counseling close friends or family members, and engaging in personal virtual relationships with current clients, many “gray areas” remain. Do social relationships necessarily interfere with a therapeutic relationship? Some would say that counselors and clients can handle such relationships as long as the priorities are clear. For example, some peer counselors believe friendships before or during counseling are positive factors in building cohesion and trust. Others take the position that counseling and friendships do not mix well. They claim that attempting to manage a social and a professional relationship simultaneously can have a negative effect on the therapeutic process, the friendship, or both.

What about socializing with former clients, or developing a friendship with former clients? Although mental health professionals are not legally or ethically prohibited from entering into a nonsexual relationship with a client after the termination of therapy, the practice could lead to difficulties for both client and counselor. The imbalance of power may change very slowly, or not at all. Counselors should be aware of their own motivations, as well as the motivations of their clients, when allowing a professional relationship to eventually evolve into a personal one, even after termination. When all things are considered, it is probably wise to avoid socializing with former clients.

Another relationship-oriented question relates to the appropriate limits of counselor self-disclosure with clients. Although some therapist self-disclosure can facilitate the therapeutic process, excessive or inappropriate self-disclosure can have a negative effect.

A final related issue has to do with gifts. When is it appropriate or inappropriate to accept a gift that a client has offered? These questions are explored in the following sections.

Counseling a Friend or Acquaintance

Many writers have cautioned against counseling a friend, and the ACA Code of Ethics (ACA, 2014) expressly prohibits counseling close friends. Kitchener and Harding (1990) point out that counseling relationships and friendships differ in function and purpose. We agree that the roles of counselor and friend are incompatible. Friends do not pay their friends a fee for listening and caring. It will be difficult for a counselor who is also a friend to avoid crossing the line between empathy and sympathy. It hurts to see a friend in pain. Because a dual relationship is created, it is possible that one of the relationships—professional or personal—will be compromised. It may be difficult for the counselor to confront the client in therapy for fear of damaging the friendship. It is also problematic for clients, who may hesitate to talk about deeper struggles for fear that their counselor/friend will lose respect for them. Counselors who are tempted to enter into a counseling relationship with a friend would do well to ask themselves whether they are willing to risk losing the friendship.

A question remains, however, as to where to draw the line. Is it ethical to counsel a mere acquaintance? A friend of a friend? A relative of a friend? We think it is going to absurd lengths to insist that counselors have no other relationship, prior or simultaneous, with their clients. Often clients seek us out for the very reason that we are not complete strangers. A client may have been referred by a mutual friend or might have attended a seminar given by the counselor. A number of factors may enter into the decision as to whether to counsel someone we know only slightly or indirectly.

Borys (1988) found that male therapists, therapists who lived and worked in small towns, and therapists with 30 or more years of experience all rated remote dual professional roles (as in counseling a client’s friend, relative, or lover) as significantly more ethical than did a comparison group. Borys speculated that men and women receive different socialization regarding the appropriateness of intruding on or altering boundaries with the opposite sex: Men are given greater permission to take the initiative or otherwise become more socially intimate. In a rural environment or a small town, it is difficult to avoid other relationships with clients who are likely to be one’s banker, beautician, store clerk, or plumber. Perhaps more experienced therapists believe they have the professional maturity to handle dualities, or it could be that they received their training at a time when dual relationships were not the focus of much attention in counselor education programs. Whatever one’s gender, work setting, or experience level, these boundary questions will arise for counselors who conduct their business and social lives in the same community.

A good question to ask is whether the nonprofessional relationship is likely to interfere, at some point, with the professional relationship. Sound professional judgment is needed to assess whether objectivity can be maintained and role conflicts avoided. Yet we need to be careful not to place too much value on “objectivity.” Being objective does not imply a lack of personal caring or subjective involvement. Although it is true that we do not want to get lost in the client’s world, we do need to enter this world to be effective.

A special kind of dual relationship dilemma can arise when a counselor needs counseling. Therapists are people, too, and have their own problems. Many of us will want to talk to our friends, who might be therapists, to help us sort out our problems. Our friends can be present for us in times of need and provide compassion and caring, although not in a formal therapeutic way. We will not expect to obtain long-term therapy with a friend, nor should we put our friends in a difficult position by requesting such therapy.

A related boundary consideration is how to deal with clients who want to become our friends via the Internet. It is not unusual for a counselor to receive a “Friend Request” from a client or former client. For counselors who are considering using Facebook, a host of ethical concerns about boundaries, dual relationships, and privacy are raised. Spotts-De Lazzer (2012) claims that practitioners will have to translate and maintain traditional ethics when it comes to social media. Spotts-De Lazzer offers these recommendations to help counselors manage their presence on Facebook:

· Limit what is shared online.

· Include clear and thorough social networking policies as part of the informed consent process.

· Regularly update protective settings because Facebook options are constantly changing.

Zur and Zur (2011) have outlined a number of questions therapists should reflect on before agreeing to become involved as a friend on Facebook or some other form of social media. Some of these questions include:

· What is on the Facebook profile?

· What is the context of counseling?

· Who is the client, and what is the nature of the therapeutic relationship?

· Why did the client post the request?

· What is the meaning of the request?

· Where is the counseling taking place?

· What does being a “Friend” with this client mean for the therapist and for the client?

· What are the ramifications of accepting a Friend Request from a client for confidentiality, privacy, and record keeping?

· Does accepting a Friend Request from a client constitute a dual relationship?

· How will accepting the request affect treatment and the therapeutic relationship?

As is evident by considering this list of questions, the issue of whether or not to accept a client’s Friend Request is quite complex and requires careful reflection and consultation. To read more about this topic, visit the Zur Institute at

http://www.zurinstitute.com/

Socializing With Current Clients

Socializing with current clients may be an example of a boundary crossing if it occurs inadvertently or infrequently or of an inappropriate dual relationship, depending on the nature of the socializing. A social relationship can easily complicate keeping a therapeutic relationship on course. Caution is recommended when it comes to establishing social relationships with former clients, and increased caution is needed before blending social and professional relationships with current clients. Among Borys’s (1988) findings were that 92% of respondents believed that it was never or only rarely ethical to invite clients to a personal party or social event; 81% gave these negative ratings to going out to eat with a client after a session. Respondents felt less strongly about inviting clients to an office or clinic open house (51% viewed this as never or rarely ethical) or accepting a client’s invitation to a special occasion (33%).

One important factor in determining how therapists perceive social relationships with clients may be their theoretical orientation. Borys found psychodynamic practitioners to be the most concerned about maintaining professional boundaries. One reason given for these practitioners’ opposition to dual role behaviors was that their training promotes greater awareness of the importance of clear, nonexploitive, and therapeutically oriented roles and boundaries. In the psychodynamic view, transference phenomena give additional meaning to alterations in boundaries for both client and therapist. A further explanation is that psychodynamic theory and supervision stress an informed and scrupulous awareness of the role the therapist plays in the psychological life of the client—namely, the importance of “maintaining the frame of therapy.”

A counselor’s stance toward socializing with clients appears to depend on several factors. One is the nature of the social function. It may be more acceptable to attend a client’s special event such as a wedding than to invite a client to a party at the counselor’s home. The orientation of the practitioner is also a factor to consider. Some relationship-oriented therapists might be willing to attend a client’s graduation party, for instance, but a psychoanalytic practitioner might feel uncomfortable accepting an invitation for any out of the office social function. This illustrates how difficult it is to come up with blanket policies to cover all situations.

· What are your views about socializing with current clients?

· Do you think your theoretical orientation influences your views?

· Under what circumstances might you have contact with a client out of the office?

Social Relationships With Former Clients

Having considered the matter of socializing with current clients, we now look at posttermination social relationships between counselors and clients. Few professional codes specifically mention social relationships with former clients. An exception is the Canadian Counselling and Psychotherapy Association (2007) code of ethics:

Counsellors remain accountable for any relationships established with former clients. Those relationships could include, but are not limited to those of a friendship, social, financial, and business nature. Counsellors exercise caution about entering any such relationships and take into account whether or not the issues and relational dynamics present during the counselling have been fully resolved and properly terminated. In any case, counsellors seek consultation on such decisions. (B.11.)

In the first edition of this book, we noted that Kitchener (1992) described the nature of the relationship once the therapeutic contract has been terminated as one of the most confusing issues for counselors and their clients. Clients may fantasize that their counselors will somehow remain a significant part of their lives as surrogate parents or friends. Counselors are sometimes ambivalent about the possibility of continuing a relationship because they are aware of real attributes of clients that under other circumstances might make them desirable friends, colleagues, or peers.

Nonetheless, there are real risks that need to be considered. Studies have suggested that memories of the therapeutic relationship remain important to clients for extended periods after termination and that many clients consider reentering therapy with their former therapists (Vasquez, 1991). This reentry option is closed if other relationships have ensued. Kitchener (1992) maintains that the welfare of the former client and the gains that have been made in counseling are put at risk when new relationships are added to the former therapeutic one. Kitchener suggests that many of the same dynamics may be operating in nonsexual posttherapy relationships as in sexual ones, although not at the same level of emotional intensity. Her conclusion is that counselors should approach the question of posttherapy relationships with care and with awareness of their strong ethical responsibility to avoid undoing what they and their clients have worked so hard to accomplish.

Two studies reveal that there is little consensus among therapists regarding whether nonromantic relationships between therapists and former clients are ethical. The majority of the participants in a study by Anderson and Kitchener (1996) did not hold to the concept of “once a client, always a client” with respect to nonsexual posttherapy relationships. Some participants suggested that posttherapy relationships were ethical if a certain time period had elapsed. Others proposed that such relationships were ethical if the former client decided not to return to therapy with the former therapist and if the posttherapy relationship did not seem to hinder later therapy with different therapists.

Another study by Salisbury and Kinnier (1996) found similar results regarding counselors’ behaviors and attitudes regarding friendships with former clients. The major finding was that many counselors are engaged in posttermination friendships and believe that under certain circumstances such relationships are acceptable. Seventy percent of the counselors believed that posttermination friendships were ethical approximately 2 years after termination of the professional relationship. Although most codes of ethics now specify a minimum waiting period for sexual relationships with former clients, the codes do not address the issue of friendships with former clients.

In reviewing the codes of ethics of the various professional organizations, it appears that entering into social relationships with former clients is not considered unethical, yet the practice could become problematic. The safest policy is probably to avoid developing social relationships with former clients. Even after the termination of a therapeutic relationship, former clients may need or want our professional services at some future time, which would be ruled out if a social relationship has been established.

· What are your thoughts about social relationships with former clients?

· Do you think codes of ethics should specifically address nonromantic and nonsexual posttherapy relationships?

· Under what circumstances might such relationships be unethical?

· When might you consider them to be ethical?

A Contributor’s Perspective

Ed Neukrug presents a personal perspective on a study he and a colleague conducted in 2011 on counselors’ perceptions of ethical and unethical behaviors. Participants rated 77 behaviors, and many of these behaviors pertained to boundary issues.

Making Ethical Decisions When Faced With Thorny Boundary Issues

Ed Neukrug

The updated version of the study identified 77 behaviors (see Neukrug & Milliken, 2011). Although we kept some of the original items from the Gibson and Pope study, we did not include items for which there had been close to 100% agreement by counselors in the original study. For instance, we did not ask if it was ethical to have sex with clients or to work while drunk. In the original study, just about every counselor felt strongly that those behaviors were unethical, and we knew from years of teaching that counselors had a clear understanding that behaviors such as these were unethical. We wanted to make sure the new survey reflected current codes. For instance, since 1993 the ACA Code of Ethics has twice been revised, with the latest Code replacing the term clear and eminent danger with serious and foreseeable harm; increasing restrictions on romantic and sexual relationships; including a statement on the permissibility of end-of-life counseling for terminally ill clients; increasing attention to social and cultural issues; allowing counselors to refrain from making a diagnosis; highlighting the importance of having a scientific basis for treatment; requiring counselors to have a transfer plan for clients; adding technology guidelines; including a statement about the right to confidentiality for deceased clients; and softening the permissibility of dual relationships, now often referred to as multiple relationships (ACA, 2005; Kaplan et al., 2009).

The new survey kept about one third of the original items, revised about one third of the original items, and included about one third new items that reflected changes since 1993. The new survey asked counselors to identify whether each of the 77 counselor behaviors were ethical or not ethical and to rate each counselor behavior on a 10-point Likert-type scale indicating how strongly they felt about their responses (1 = not very strongly, 10 = very strongly). In addition, the new survey asked counselors whether they had received ethics training in their program or elsewhere. Here we found some interesting results compared to the Gibson and Pope (1993) study.

Whereas Gibson and Pope found 73% of respondents had ethics training, a resounding 97.8% of counselors in our survey stated they had ethics training. Similarly, whereas 29% of counselors in the Gibson and Pope study reported taking a formal ethics course, this study found 60% had taken one ethics course, and 60% had taken more than one ethics course. In addition, a similar number stated that ethics training was infused throughout their program. The increase in ethics training demonstrates a major shift nationally and is likely the result of a number of changes. For instance, the increase in the number of programs accredited by the Council for Accreditation of Counseling and Related Educational Programs (CACREP) has undoubtedly affected these statistics because CACREP requires students to learn about ethics (CACREP, 2009; Urofsky & Sowa, 2004). This growth in ethics training is probably also the result of credentialing boards increasingly requiring ethics training when professionals obtain or renew their credentials (National Board for Certified Counselors, 2012). Also, as society has become increasingly litigious, the importance of ethics training to avoid malpractice lawsuits has become paramount (Neukrug, Milliken, & Walden, 2001; Remley & Herlihy, 2014; Saunders, Barros-Bailey, Rudman, Dew, & Garcia, 2007). Finally, this greater focus on ethics training has probably fostered a surge in scholarly materials (e.g., journal articles) that increase knowledge of ethics among professionals.

Counselor Perceptions of Boundary Crossings

There is an expectation placed on counselors to maintain the sanctity of the counseling relationship by maintaining boundaries between themselves and the clients they serve (Remley & Herlihy, 2014). Our ethics codes tend to support this perspective, highlighting behaviors that should be avoided to protect our clients from injury. Our professional associations expect counselors to exhibit certain behaviors that respect boundaries between counselors and clients, and clients generally have a fairly good sense of what is “right and wrong” within the relationship regarding boundaries. Of course, it helps if clients have a clear understanding of these boundaries, and counselors can provide clients with an informed consent statement that addresses issues of boundaries in the relationship and the ethics code from the counselor’s professional association.

Despite expectations from our professional associations and dictates from our ethics codes, many boundary issues are complicated, and, as noted earlier in the chapter, sometimes an intentional and thoughtful boundary crossing can be helpful to the counseling relationship (G. Corey et al., 2015; Moleski & Kiselica, 2005; Zur, 2007). Although our survey examined counselors’ beliefs regarding a wide range of behaviors, a number of items specifically addressed boundary issues, the focus of this book. We have teased out those items and present them in

Table 1.1

. For the complete study results, see Neukrug and Milliken (2011).

Table 1.1

Counselors′ Perceptions Regarding Boundary Issues

5.4

6.7

6.8

−2.1

6.7

6.2

5.8

4.6

4.5

−6.6

4.6

5.3

3.7

4.6

−7.8

3.6

0.6

99.4

−9.2

Percentage	Strength of Response
Item Number and Behavior	Ethical	Unethical	M	SD
1. Breaking confidentiality if the client is threatening harm to self	95.7	4.3	8.73		3.6
2. Having clients address you by your first name	94.9	5.1	7.41	3.9
3. Using an interpreter when a client’s primary language is different from yours	88.8	11.2		5.4	5.0
4. Self-disclosing to a client	8 6.8	13.2	4.4	4.7
5. Consoling your client by touching him or her (e.g., placing your hand on his or her shoulder)	83.9	16.1		4.5	5.2
6. Publicly advocating for a controversial cause	83.6	1 6.4	4.2
7. Attending a client’s wedding, graduation ceremony, or other formal ceremony	7 2.1	27.9	2.2		5.8
8. Hugging a client	6 6.7 )	33.3	1.7	5.5
9. Counseling a pregnant teenager without parental consent	6 2.0	38.0	1.5			6.7
10. Telling your client you are angry at him or her	61.5	38.5	1.0
11. Withholding information about a minor client despite a parent’s request for information	47.4	52.6	−0.7		6.8
12. Pressuring a client to receive needed services	43.3	56.7	−0.9	6.4
13. Becoming sexually involved with a former client (at least 5 years after the counseling relationship ended)	42.9	57.1		−2.1
14. Guaranteeing confidentiality for group members	36.9	6 3.1	7.5
15. Sharing confidential client information with a colleague who is not your supervisor	29.4	7 0.6	−3.5
16. Engaging in a helping relationship with a client (e.g., individual counseling) while the client is in another helping relationship (e.g., family counseling) without contacting the other counselor	26.8	73.2	−4.0		6.2
17. Seeing a minor client without parental consent	25.4	7 4.6	−4.3
18. Viewing your client’s personal Web page (e.g., MySpace, Facebook, blog) without informing your client	22.5	77.5	−4.7
19. Becoming sexually involved with a person your client knows well	22.3	77.7	−5.1	5.9
20. Trying to change your client’s values	1 3.4	86.6	−6.5		5.3
21. Kissing a client as a friendly gesture (e.g., greeting)	12.5	87.5		−6.6				4.6
22. Accepting a gift worth more than $25 from a client	11.7	88.3	−6.1
23. Revealing confidential information if a client is deceased	11.6	88.4	−6.0
24. Engaging in a professional counseling relationship with a colleague who works with you	10.7	89.3		−7.8		3.7
25. Engaging in a dual relationship (e.g., your client is also your child’s teacher)	10.4	89.6
26. Telling your client you are attracted to him or her	10.3	89.7	−7.6
27. Giving a gift worth more than $25 to a client	94.7	−7.5
28. Engaging in a professional counseling relationship with a friend	95.4
29. Lending money to your client	3.4	96.6	−8.3	3.1
30. Revealing a client’s record to the spouse of a client without the client’s permission		0.6		99.4		−9.2	2.1
31. Attempting to persuade your client to adopt a religious conviction you hold	2.0

Context Is Everything

In reviewing
Table 1.1
, it is clear that many counselors believe certain behaviors to be acceptable even though they will affect the boundary between counselor and client. For instance, more than 85% of counselors believed these behaviors are ethical: “breaking confidentiality if the client is threatening harm to self,” “having clients address you by your first name,” “using an interpreter when a client’s primary language is different from yours,” and “self-disclosing to a client.” However, even when the vast majority of counselors believe a behavior to be ethical, their actual responses may vary dramatically as a function of the context. For instance, a counselor doesn’t break confidentiality in all cases of potential “harm to self.” Rather, the decision depends on the seriousness of the thoughts, the likelihood of the action, and the means available to the client. Similarly, although many counselors may feel comfortable having clients address them by their first names, in some cases, depending on the professional style of the counselor or the issues of the client (a client who has boundary issues in his or her life), a counselor may decide it is important for a client to not address the counselor by his or her first name. Although it may be acceptable and even important to use an interpreter in a counseling relationship, a counselor must consider whether the interpreter is trustworthy and can keep the conversation confidential and how the use of an interpreter might affect the willingness of the client to discuss embarrassing or shameful material. It may be better to refer this client to a person who speaks the client’s language. Finally, although incidental self-disclosures such as “I’m so proud of you” or “I love your outfit today” can add to the working alliance, we are all aware that inappropriate self-disclosures that reveal too much about the counselor, or are done for the wrong reasons, can wreak havoc in the helping relationship.

Similarly, most counselors believe a number of behaviors are unethical most of the time and would negatively affect the boundary within the helping relationship if practiced. But even here context is everything, and a counselor might decide to exhibit the behavior in certain circumstances. Consider the following behaviors from
Table 1.1
that most counselors view as unethical. Then look at the corresponding counselor situation in which exhibiting such a behavior might be acceptable.

1. Item 20: Trying to change your client’s values

1. A counselor working with a client who uses corporal punishment suggests other ways that the client can parent, shows her “positive parenting” techniques, and points out the research regarding the effectiveness of positive parenting and the ineffectiveness of corporal punishment.

2. Item 21: Kissing a client as a friendly gesture (e.g., greeting)

1. A counselor and client share a cultural heritage in which a kiss on the cheek is usual and expected.

3. Item 22: Accepting a gift worth more than $25 from a client

1. A client who is terminating counseling after years of work with a counselor gives the counselor a $30 book as a thank-you for their work together.

4. Item 24: Engaging in a professional counseling relationship with a colleague who works with you

1. The only counselor in an area practicing a neuroprocessing technique to relieve stress migraines is asked by a coworker to work with him for the three sessions needed to learn the process.

5. Item 25: Engaging in a dual relationship (e.g., your client is also your child’s teacher)

1. A new client comes to counseling and the counselor realizes that the two of them are in the same exercise class. Together, they decide they can manage the dual relationship.

6. Item 26: Telling your client you are attracted to him or her

1. Having worked with a depressed client for a while who has recently made some significant changes, a counselor says, “You have such an attractive smile when your depression lifts.”

7. Item 27: Giving a gift worth more than $25 to a client

1. A client with whom you have worked has focused on improving her life. One area in which she has worked long and hard is obtaining her general equivalency diploma (GED). After 2 years of hard work, she obtains her GED. You decide to have her diploma framed as a reinforcement of her hard work.

Reflecting on Context

Despite the fact that the behaviors just discussed were seen as mostly ethical (Items 1–5) or mostly unethical (Items 20–27) by the vast majority of counselors, responses can still vary as a function of context. In our survey, counselors had a fair amount of disagreement regarding whether some items were ethical or unethical (Items 5–19). These behaviors represent situations in which counselors might struggle. Keeping context in mind, review these behaviors and consider when you believe it might be appropriate or inappropriate to exhibit the behaviors. Finally, you might also want to tackle the last four items (Items 28–31) and consider whether there is ever a time when such behaviors might be ethical.

Ethical decision making around boundary issues can be a complex and difficult process, and responses may not always be as obvious as we might expect. Knowing your client, yourself, and the context of the particular ethical dilemma can help you make a wise decision in the client’s best interests.

A Contributor’s Perspective

Arnold A. Lazarus presents a provocative argument that strict boundary regulations may have a negative impact on therapeutic outcomes. He encourages therapists to avoid practicing defensively and to be willing to think and venture outside the proverbial box.

Transcending Boundaries in Psychotherapy

Arnold A. Lazarus

Some of the practitioners were so rigid that if they walked into a restaurant and saw one of their analysands they would leave immediately. Even when the field became more eclectic, many analytic proscriptions and prohibitions spilled over and were adopted by most therapists. Subsequently, when rules of ethics were first drawn up, any form of fraternization with a client was frowned upon, and dual relationships were considered taboo. During my internship in 1957 two of my peers were severely reprimanded: one for sharing tea and cookies with a client, and the other for helping a woman on with her coat.

As my orientation became behavioral and the theories and methods I applied differed significantly from psychoanalytic and psychodynamic approaches, I argued that there was no need to subscribe to their rules of client–therapist interaction. Far from being a “screen,” I was a fellow human being who considered it important to treat clients with dignity, respect, decency, and equality. Indeed, “breaking bread” with some clients fostered closer rapport, as did some out-of-office experiences such as driving a client to the train station on a cold rainy day. It always struck me as very impolite, if not insulting, to answer a question with a question instead of answering the question and then inquiring why that issue had been raised. One of my clients complained that when he asked his psychodynamic therapist a noninvasive and not too personal question she said, “We are not here to discuss me.” He said he felt demeaned and terminated the therapy soon thereafter.

To balance the playing field, it is necessary to remember that most rules have exceptions, and it is essential to observe certain caveats. There are clients with whom clear-cut boundaries are necessary. People who fit into certain diagnostic categories or evince certain behaviors require a definite structure and clear-cut boundaries: for example, those with psychoses, bipolar depression, borderline personalities, antisocial tendencies, substance abuse, histrionic personality disorders, character pathology, suicidal behaviors, eating disorders (especially anorexia nervosa), self-injurious behaviors, or criminal proclivities. A definite structure and clear-cut boundaries are not an invitation to mete out or exhibit nonempathic behavior, impolite comments, judgmental statements, or insulting remarks. The reason I am underscoring these issues is because many people have erroneously concluded that I am advocating a laissez-faire and capricious fraternization with all clients. It is necessary to be wary and well informed before deciding that it would be in the client’s best interests to stretch or cross certain boundaries. I am opposed to clinicians who treat all their clients in the same way and always go by the book. I reiterate that while deciding whether or not to traverse demarcated boundaries, if one has any misgivings, it is best to err on the side of caution.

A prevalent practice that tends to handicap therapists and often leads them to harm rather than to help certain clients or patients is therapists’ insistence on maintaining strict boundaries. They practice defensively, guided by their fear of licensing boards and attorneys rather than by clinical considerations. Risk management seminars typically warn therapists that if they cross boundaries severely negative consequences from licensing boards and ethics committees are likely to ensue. For example, they are warned not to fraternize or socialize with clients and are told to steer clear of any mutual business transactions (other than the fee for service). They are advised to avoid bartering and to avoid working with or seeing a client outside the office. Yet those therapists who transcend certain boundaries with selected clients often provide superior help. They rely on their own judgment and refuse to hide behind barriers or to function within a metaphorical straitjacket. Great benefits can accrue when therapists are willing to think and venture outside the proverbial box. Here is a case in point.

Paul, aged 17, required help for some potentially serious drug problems. His parents had tried to find a therapist who could treat and assist him, but to no avail. Paul had initial meetings with four different therapists over a 6-week interval but declared each one “a jerk” and refused to go back. He then reluctantly consulted a fifth therapist (who had been one of my recent postdoctoral students) who quickly sized up the situation. He realized that Paul would regard any formal meeting with a professional therapist as reminiscent of his uptight parents and strict teachers, so he would resist their ministrations. The therapist cleverly stepped out of role and invited Paul to shoot some baskets with him later that day at a nearby basketball court. It took several weeks of basketball playing and informal chatting before adequate rapport and trust were established, at which point Paul was willing to engage in formal office visits and seriously address his problems.

This innovative, free-thinking, and creative therapist was willing to take a risk and cross a boundary, and in so doing he gained the trust of a young man who was really hurting emotionally. This enabled Paul to respond to the therapist as a kind and accomplished big brother he could look up to and from whom he could learn a good deal.

Why have psychotherapists found it necessary to form ethics committees; establish a wide range of principled dos and don’ts; and police, discipline, and penalize those who cross the line? This is probably in response to the extreme laissez-faire climate of therapeutic interaction that prevailed in the 1950s and 1960s, when blatant boundary crossings were openly espoused. For example, at Esalen in California, where Frederick (Fritz) Perls and his associates established a training and therapy institute, therapists and clients often became playmates and even lovers. It is not far fetched to look upon many of their dealings as flagrant acts of malpractice. Concerned professionals became aware of the emotional damage that was being wrought in many settings and sought to establish a code of ethics and to lay down basic ground rules for practitioners. Terms like boundaries, boundary violation, and standard of care entered the vernacular.

Today, all therapists are expected to treat their clients with respect, dignity, and consideration and to adhere to the spoken and unspoken rules that make up our established standards of care. Many of these rules are necessary and sensible. For instance, it is essential for therapists to avoid any form of exploitation, harassment, harm, or discrimination, and it is understandable that a sexual relationship with a client is considered an ultimate taboo. Emphasis is placed on the significance of respect, integrity, confidentiality, and informed consent. Nevertheless, some elements of our ethics codes have become so needlessly stringent and rigid that they can undermine effective therapy. The pendulum has swung too far in the opposite direction from the era of negligent free-for-all indulgence.

One of my major concerns is that there is a widespread failure to grasp the critical difference between “boundary violations,” which can harm a client, and “boundary crossings,” which produce no harm and may even enhance the therapeutic connection. For example, what would be so appalling about a therapist saying to a client who has just been seen from 11 a.m. until noon: “We seem to be onto something important. Should we go and pick up some sandwiches at the local deli, and continue until 1 p.m. at no extra fee to you?” Strict boundary proponents would regard such behavior as unethical because it goes outside the therapeutic frame. However, strategic therapists would argue that rigid adherence to a particular frame and setting only exacerbates problems, especially in nonresponsive patients. For example, a patient of mine who had been resistant and rather hostile arrived early for his appointment. I was just finishing lunch and had some extra sandwiches on hand, so I offered him one. He accepted my offer as well as a glass of orange juice. Coincidentally or otherwise, thereafter our rapport was greatly enhanced, and he made significant progress. What became clear during our ensuing sessions was that the act of literally breaking bread led him to perceive me as humane and caring and facilitated his trust in me.

Over the past 40 years, I have seen thousands of clients and have selectively transcended boundaries on many occasions. For example, I engaged in barter with an auto mechanic, who tuned my car in exchange for three therapy sessions. I have accepted dinner invitations from some clients, have attended social functions with others, played tennis with several clients, and ended up becoming good friends with a few. Of course, I do not engage in such behaviors capriciously. Roles and expectations must be clear. Possible power differentials must be kept in mind. For my own protection as well as the client’s protection, I don’t engage in these behaviors with seriously disturbed people, especially those who are hostile, paranoid, aggressive, or manipulative. But the antiseptic obsession with “risk management” has led far too many therapists to practice their craft in a manner that is needlessly constraining and often countertherapeutic.

Those therapists who rigidly adhere to strict professional boundaries are apt to place risk management ahead of humane interventions. The manner in which they speak to their clients often leaves much to be desired. For example, I recently attended a clinical meeting at which a young psychiatrist was interviewing a woman who suffered from an eating disorder, bulimia nervosa. At one point the dialogue continued more or less as follows:

1. Patient: May I ask how old you are?

2. Therapist: Why is that important?

3. Patient: It’s no big deal. I was just curious.

4. Therapist: Why would you be curious about my age?

5. Patient: Well, you look around 30, and I was just wondering if I am correct.

6. Therapist: What impact would it have if you were not correct?

7. Patient: None that I can think of. It was just idle curiosity.

8. Therapist: Just idle curiosity?

As I watched these exchanges, I grew uncomfortable. It seemed to me that the patient wished she had never raised the issue in the first place and that she was feeling more and more uneasy. It did not seem that the dialogue was fostering warmth, trust, or rapport. On the contrary, it resembled a cross-examination in a courtroom and appeared adversarial.

In psychoanalysis it is deemed important for the analyst to remain neutral and nondisclosing so the patient can project his or her needs, wishes, and fantasies onto a “blank screen.” But it makes no sense for this to become a rule for all therapists to follow. It has always struck me as ill mannered and discourteous to treat people this way.

I recommend the following type of exchange in place of the aforementioned example:

1. Patient: How old are you?

2. Therapist: I just turned 30. Why do you ask?

3. Patient: I was just curious. It’s no big deal.

4. Therapist: Might you be more comfortable with or have greater confidence in someone younger or older?

5. Patient: No, not at all.

At this juncture, I would suggest that the topic be dropped. Notice the recommended format. First answer the question and then proceed with an inquiry if necessary. In this way, the patient is validated and not demeaned. Why am I dwelling on such a seemingly trivial issue? Because it is not a minor or frivolous point, and I have observed this type of interaction far too often, usually to the detriment of the therapeutic process. I see it as part and parcel of a dehumanizing penchant among the many rigid thinkers in our field who legislate against all boundary extensions. These are the members of our profession (and they are not a minority) who regard themselves as superior to patients and tend to infantilize and demean them in the process.

The purpose of this essay is to alert readers to an issue that is crucial in the field of psychotherapy. I have coedited a book (Lazarus & Zur, 2002) on the subject of boundaries and boundary crossings in which various contributors have addressed the topic from many viewpoints: nonanalytic practice procedures, feminist perspectives, military psychology, counseling centers, deaf communities, legal issues, gay communities, and rural settings (among others). It is generally agreed that the client–therapist relationship is at the core of treatment effectiveness. Yet by adhering to strict boundary regulations, many troublesome feelings are likely to arise and ruptures to emerge that destroy the necessary sense of trust and empathy. Greenspan (2002) aptly describes strict boundary adherence as a “distance model” that undermines the true healing potential of the work we do. I fully concur with her opinion that we need an approach of respectful compassion. Safe connection between therapist and client should be the overriding aim because this, not strict boundaries, will protect clients from abuse.

Conclusions

In this introductory chapter, we have examined what the codes of ethics of the major professional associations advise with respect to dual or multiple relationships. We have explored a number of factors that make such relationships problematic, as well as factors that create a potential for harm and the risks to parties directly or not directly involved in multiple relationships. Some strategies for reducing risks were described.

It is critical that counselors give careful thought to the potential complications before they become entangled in ethically questionable relationships. The importance of consultation in working through these issues cannot be overemphasized. As with any complex ethical issue, complete agreement may never be reached, nor is it necessarily desirable. However, as conscientious professionals, we need to strive to clarify our own stance and develop our own guidelines for practice within the limits of codes of ethics and current knowledge.

Chapter 1
Boundary Issues in Perspective
Dual or multiple relationships occur when a professional assumes two or more roles simultaneously or sequentially with a person seeking his or her help. This may involve taking on more than one professional role (such as counselor and teacher) or combining professional and nonprofessional roles (such as counselor and friend or counselor and lover). Another way of stating this is that a helping professional enters into a dual or multiple relationship whenever the professional has another, significantly different relationship with a client, a student, or a supervisee.
Multiple relationship issues exist throughout our profession and affect virtually all counselors, regardless of their work setting or the client populations they serve. Relationship boundary issues have an impact on the work of helping professionals in diverse roles, including counselor educator, supervisor, agency counselor, private practitioner, school counselor, college or university student personnel specialist, rehabilitation counselor, and practitioner in other specialty areas. These issues affect the dyadic relationship between counselor and client, and they can also emerge in complex ways in tripartite relationships (such as client/supervisee/supervisor or client/consultee/consultant) and in family therapy and group work. No professional remains untouched by the potential difficulties inherent in dual or multiple relationships.
This book is a revision of our earlier editions, Dual Relationships in Counseling (Herlihy & Corey, 1992) and Boundary Issues in Counseling: Multiple Roles and Responsibilities (Herlihy & Corey, 1997, 2006b), but with an expanded focus. Since we last wrote together about this topic, helping professionals have continued to debate issues of multiple relationships, roles, and responsibilities; power; and boundaries in counseling.
Because of the complexities involved, the term multiple relationship is often more descriptive than dual relationship. Dual or multiple relationships occur when mental health practitioners interact with clients in more than one relationship, whether professional, social, or business. In the most recent versions of the ACA Code of Ethics (American Counseling Association [ACA], 2005, 2014), both of these terms have been replaced with the term nonprofessional interactions to indicate those additional relationships other than sexual or romantic ones. In this book, we continue to use the terms dual or multiple relationships to describe these nonprofessional relationships as well as dual professional relationships.
This revised edition is based on the assumption that counseling professionals must learn how to manage multiple roles and responsibilities (or nonprofessional interactions or relationships) effectively rather than learn how to avoid them. This entails managing the power differential inherent in counseling or training relationships, balancing boundary issues, addressing nonprofessional relationships, and striving to avoid using power in ways that might cause harm to clients, students, or supervisees. This book rests on the premise that we can develop ethical decision-making skills that will enable us to weigh the pros and cons of multiple roles and nonprofessional interactions or relationships.
Beginning in the 1980s, the counseling profession became increasingly concerned with the ethical issues inherent in entering into multiple relationships and establishing appropriate boundaries. Much has been written since then about the harm that results when counseling professionals enter into sexual relationships with their clients. Throughout the 1980s, sexual misconduct received a great deal of attention in the professional literature, and the dangers of sexual relationships between counselor and client, professor and student, and supervisor and supervisee have been well documented. Today there is clear and unanimous agreement that sexual relationships with clients, students, and supervisees are unethical, and prohibitions against them have been translated into ethics codes and law. Even those who have argued most forcefully against dual relationship prohibitions (e.g., Lazarus & Zur, 2002; Zur, 2007) agree that sexual dual relationships are never acceptable. We examine the issue of sexual dual relationships in detail in
Chapter 2
.
In the 1990s and until the turn of the century, nonsexual dual and multiple relationships received considerable attention in professional journals and counseling textbooks. The codes of ethics of the ACA 2014), the American School Counselor Association (ASCA; 2010), the American Psychological Association (APA; 2010), the National Association of Social Workers (NASW; 2008), and the American Association for Marriage and Family Therapy (AAMFT; 2012) have all dealt specifically and extensively with topics such as appropriate boundaries, recognizing potential conflicts of interest, and ethical means for dealing with dual or multiple relationships. Since this book was last revised in 2006, new articles on these topics have slowed to a trickle in the professional literature. There has been an increasing recognition and acceptance that dual or multiple relationships are often complex, which means that few simple and absolute answers can neatly resolve ethical dilemmas that arise. It is not always possible for counselors to play a singular role in their work, nor is this always desirable. From time to time we all will wrestle with how to balance multiple roles in our professional and nonprofessional relationships. Examples of problematic concerns associated with dual relationships include whether to barter with a client for goods or services, whether it is ever acceptable to counsel a friend of a friend or social acquaintance, whether to interact with clients outside the office, how a counselor educator might manage dual roles as educator and therapeutic agent with students, how to ethically conduct experiential groups as part of a group counseling course, and whether it is acceptable to develop social relationships with a former client.
In this chapter, we focus on nonsexual dual relationships that can arise in all settings. One of our guest contributors, Arnold Lazarus, makes a case for the potential benefits of transcending boundaries. He takes the position that benefits can accrue when therapists are willing to think and venture outside the proverbial box. The following questions will guide our discussion:
· What guidance do our codes of ethics offer about dual or multiple nonprofessional relationships?
· What makes dual or multiple relationships problematic?
· What factors create the potential for harm?
· What are the risks (and benefits) inherent in dual or multiple relationships, for all parties involved?
· What important but subtle distinctions should be considered?
· What safeguards can be built in to minimize risks?
Ethical Standards
The codes of ethics of all the major associations of mental health professionals address the issue of multiple relationships. To begin our discussion, consider these excerpts from the codes of ethics for mental health counselors, marriage and family therapists, social workers, school counselors, and psychologists.
The ACA Code of Ethics (ACA, 2014) provides several guidelines regarding nonprofessional interactions. Counselors are advised that:
Sexual and/or Romantic Relationships Prohibited
Sexual and/or romantic counselor–client interactions or relationships with current clients, their romantic partners, or their family members are prohibited. This prohibition applies to both in-person and electronic interactions or relationships. (Standard A.5.a.)
Previous Relationships
Counselors consider the risks and benefits of accepting as clients those with whom they have had a previous relationship. These potential clients may include individuals with whom the counselor has had a casual, distant, or past relationship. Examples include mutual or past membership in a professional association, organization, or community. When counselors accept these clients, they take appropriate professional precautions such as informed consent, consultation, supervision, and documentation to ensure that judgment is not impaired and no exploitation occurs. (Standard A.6.a.)
Extending Counseling Boundaries
Counselors consider the risks and benefits of extending current counseling relationships beyond conventional parameters. Examples include attending a client’s formal ceremony (e.g., a wedding/commitment ceremony or graduation), purchasing a service or product provided by a client (excepting unrestricted bartering), and visiting a client’s ill family member in the hospital. In extending these boundaries, counselors take appropriate professional precautions such as informed consent, consultation, supervision, and documentation to ensure that judgment is not impaired and no harm occurs. (Standard A.6.b.)
Documenting Boundary Extensions
If counselors extend boundaries as described in A.6.a. and A.6.b., they must officially document, prior to the interaction (when feasible), the rationale for such an interaction, the potential benefit, and anticipated consequences for the client or former client and other individuals significantly involved with the client or former client. When unintentional harm occurs to the client or former client, or to an individual significantly involved with the client or former client, the counselor must show evidence of an attempt to remedy such harm. (Standard A.6.c.)
The standard of the AAMFT Code of Ethics (AAMFT, 2012) dealing with dual relationships advises therapists to avoid such relationships due to the risk of exploitation:
Marriage and family therapists are aware of their influential position with respect to clients, and they avoid exploiting the trust and dependency of such persons. Therapists, therefore, make every effort to avoid conditions and multiple relationships with clients that could impair professional judgment or increase the risk of exploitation. Such relationships include, but are not limited to, business or close personal relationships with a client or the client’s immediate family. When the risk of impairment or exploitation exists due to conditions or multiple roles, therapists document the appropriate precautions taken. (1.3.)
The NASW (2008) code of ethics, using language similar to that of the AAMFT, focuses on the risk of exploitation or potential harm to clients:
Social workers should not engage in dual or multiple relationships with clients or former clients in which there is a risk of exploitation or potential harm to the client. In instances when dual or multiple relationships are unavoidable, social workers should take steps to protect clients and are responsible for setting clear, appropriate, and culturally sensitive boundaries. (Dual or multiple relationships occur when social workers relate to clients in more than one relationship, whether professional, social, or business. Dual or multiple relationships can occur simultaneously or consecutively.) (1.06.c.)
The Ethical Standards for School Counselors (ASCA, 2010) also advises that school counselors avoid dual relationships that carry a potential risk of harm and, like the ACA, suggests safeguards. The school counselors’ code is the only one, among those reviewed here, that addresses the burgeoning usage of social media and its potential for creating inappropriate relationships between students and professionals.
Professional school counselors:
Avoid dual relationships that might impair their objectivity and increase the risk of harm to the student (e.g., counseling one’s family members, close friends or associates). If a dual relationship is unavoidable, the school counselor is responsible for taking action to eliminate or reduce the potential for harm to the student through the use of safeguards, which might include informed consent, consultation, supervision and documentation. (A.4.a.)
Maintain appropriate professional distance with students at all times. (A.4.b.)
Avoid dual relationships with students through communication mediums such as social networking sites. (A.4.c.)
The APA (2010) code addresses multiple relationships quite extensively:
(a) A multiple relationship occurs when a psychologist is in a professional role with a person and (1) at the same time is in another role with the same person, (2) at the same time is in a relationship with a person closely associated with or related to the person with whom the psychologist has the professional relationship, or (3) promises to enter into another relationship in the future with the person or a person closely associated with or related to the person.
A psychologist refrains from entering into a multiple relationship if the multiple relationship could reasonably be expected to impair the psychologist’s objectivity, competence, or effectiveness in performing his or her functions as a psychologist, or otherwise risks exploitation or harm to the person with whom the professional relationship exists.
Multiple relationships that would not reasonably be expected to cause impairment or risk exploitation or harm are not unethical.
(b) If a psychologist finds that, due to unforeseen factors, a potentially harmful multiple relationship has arisen, the psychologist takes reasonable steps to resolve it with due regard for the best interests of the affected person and maximal compliance with the Ethics Code.
(c) When psychologists are required by law, institutional policy, or extraordinary circumstances to serve in more than one role in judicial or administrative proceedings, at the outset they clarify role expectations and the extent of confidentiality and thereafter as changes occur. (3.05.)
As can be seen, the ethics codes for mental health professionals all take considerable care to address dual and multiple relationships. Ethical problems often arise when clinicians blend their professional relationships with other kinds of relationships with a client. The ethics codes of most professional organizations currently warn against crossing these boundaries when it is not in the best interests of the client. The emphasis is no longer on an outright prohibition of dual or multiple relationships; rather, the focus has shifted to avoiding the misuse of power and exploitation of the client. Also, it is increasingly acknowledged that some nonprofessional relationships are potentially beneficial.
What Makes Dual or Multiple Relationships So Problematic?
Dual and multiple relationships are fraught with complexities and ambiguities that require counselors to make judgment calls and apply the codes of ethics carefully to specific situations. These relationships are problematic for a number of reasons:
· They can be difficult to recognize.
· They can be very harmful; but they are not always harmful, and some have argued that they can be beneficial.
· They are the subject of conflicting views.
· They are not always avoidable.
Dual or Multiple Relationships Can Be Difficult to Recognize
Dual or multiple relationships can evolve in subtle ways. Some counselors, counselor educators, or supervisors may somewhat innocently establish a form of nonprofessional relationship. They may go on a group outing with clients, students, or supervisees. A counselor may agree to play tennis with a client, go on a hike or a bike ride, or go jogging together when they meet by accident at the jogging trail. Initially, this nonprofessional interaction may seem to enhance the trust needed to establish a good working relationship in therapy. However, if such events continue to occur, eventually a client may want more nonprofessional interactions with the therapist. The client may want to become close friends with the counselor and feel let down when the counselor declines an invitation to a social event. If a friendship does begin to develop, the client may become cautious about what he or she reveals in counseling for fear of negatively affecting the friendship. At the same time, the counselor may avoid challenging the client out of reluctance to offend someone who has become a friend.
It can be particularly difficult to recognize potential problems when dual relationships are sequential rather than simultaneous. A host of questions present themselves: Can a former client eventually become a friend? How does the relationship between supervisor and supervisee evolve into a collegial relationship after the formal supervision is completed? What kinds of posttherapy relationships are ever acceptable? These questions are explored in later chapters.
Dual or Multiple Relationships Are Not Always Harmful, and They May Be Beneficial
A wide range of outcomes to dual or multiple relationships is possible, from harmful to beneficial. Some dual relationships are clearly exploitive and do serious harm to the client and to the professional involved. Others are benign; that is, no harm is done. In some instances, dual relating may strengthen the therapeutic relationship. Moleski and Kiselica (2005) provide a review of the literature regarding the nature, scope, and complexity of dual relationships ranging from the destructive to the therapeutic. They suggest that counselors who begin a dual relationship are not always destined for disaster. They describe some therapeutic dual relationships that complement and enhance the counseling relationship. For example, in counseling clients from diverse cultures, practitioners may find it necessary to engage in boundary crossings to establish the counseling relationship. Moleski and Kiselica maintain that the positive or negative value of the secondary relationship is determined by the degree to which it enhances the primary counseling relationship. Therapeutic dual relationships are characterized by the counselor’s commitment to doing what is in the best interest of the client.
Consider the following two examples. The first is a harmful dual relationship; the second could be described as benign or even therapeutic.
· A high school counselor enters into a sexual relationship with a 15-year-old student client.
· All professionals agree that this relationship is exploitive in the extreme. The roles of counselor and lover are never compatible, and the seriousness of the violation is greatly compounded by the fact that the client is a minor.
· A couple plans to renew their wedding vows and host a reception after the ceremony. The couple invites their counselor, who attends the ceremony, briefly appears at the reception to offer her best wishes to the couple, and leaves. The couple is pleased that the counselor came, especially because they credit the counseling process with helping to strengthen their marriage.
· Apparently, no harm has been done. In this case the counselor’s blending of a nonprofessional role with her professional role could be argued to be benign or even beneficial to the counseling relationship.
Dual and Multiple Relationships Are the Subject of Conflicting Views
The topic of dual and multiple relationships has been hotly debated in the professional literature. A few writers argue for the potential benefits of nonsexual dual relationships, or nonprofessional relationships. Zur (2007) asserts that boundary crossings are not unethical and that they often embody the most caring, humane, and effective interventions. Other writers take a cautionary stance, focusing on the problems inherent in dual or multiple relationships and favoring a strict interpretation of ethical standards aimed at regulating professional boundaries. Persuasive arguments have been made for both points of view.
Welfel (2013) points out that many ethics scholars take a stronger stance against multiple relationships than that found in codes of ethics, especially those in which one role is therapeutic. Perhaps this is because their study of the issues has made them more keenly aware of the risks. Through their work on ethics committees, licensure boards, or as expert witnesses in court cases, they may have direct knowledge of harm that has occurred.
Even when practitioners have good intentions, they may unconsciously exploit or harm clients who are vulnerable in the relationship. If the professional boundaries become blurred, there is a strong possibility that confusion, disappointment, and disillusionment will result for both parties. For these reasons, some writers caution against entering into more than one role with a client because of the potential problems involved. They advise that it is generally a good idea to avoid multiple roles unless there is sound clinical justification for considering multiple roles.
Although dual relationships are not damaging to clients in all cases, St. Germaine (1993) believes counselors must be aware that the potential for harm is always present. She states that errors in judgment often occur when the counselor’s own interests become part of the equation. This loss of objectivity is one factor that increases the risk of harm.
Gabbard (1994) and Gutheil and Gabbard (1993) have warned of the dangers of the slippery slope. They caution that when counselors make one exception to their customary boundaries with clients, it becomes easier and easier to make more exceptions until an exception is made that causes harm. They argue that certain actions can lead to a progressive deterioration of ethical behavior. Furthermore, if professionals do not adhere to uncompromising standards, their behavior may foster relationships that are harmful to clients. Remley and Herlihy (2014) summarize this argument by stating, “The gradual erosion of the boundaries of the professional relationship can take counselors down an insidious path” (p. 206) that could even lead, ultimately, to a sexual relationship with a client.
Other writers are critical of this notion of the slippery slope, stating that it tends to result in therapists practicing in an overly cautious manner that may harm clients (Lazarus & Zur, 2002; Pope & Vasquez, 2011; Speight, 2012; Zur, 2007). Overlapping boundaries and crossing boundaries are not necessarily problematic; instead, they can be positive and beneficial within therapeutic relationships (Speight, 2012). G. Corey, Corey, Corey, and Callanan (2015) remind us that ethics codes are creations of humans, not divine decrees that contain universal truth. They do not believe dual or multiple relationships are always unethical, and they have challenged counselors to reflect honestly and think critically about the issues involved. They believe codes of ethics should be viewed as guidelines to practice rather than as rigid prescriptions and that professional judgment must play a crucial role.
Tomm (1993) has suggested that maintaining interpersonal distance focuses on the power differential and promotes an objectification of the therapeutic relationship. He suggested that dual relating invites greater authenticity and congruence from counselors and that counselors’ judgments may be improved rather than impaired by dual relationships, making it more difficult to use manipulation and deception or to hide behind the protection of a professional role.
Lazarus and Zur (2002) and Zur (2014) make the point that none of the codes of ethics of any of the various professions takes the position that nonsexual dual relationships are unethical per se. They believe that “dual relationships are neither always unethical nor do they necessarily lead to harm and exploitation, nor are they always avoidable. Dual relationships can be helpful and beneficial to clients if implemented intelligently, thoughtfully, and with integrity and care” (Lazarus & Zur, 2002, p. 472). They remind counselors that dual relationships are not, in and of themselves, illegal, unethical, unprofessional, or inappropriate. Instead, unethical dual relationships are those that are reasonably likely to exploit clients or impair professional judgment.
We agree that duality itself is not unethical; rather, the core of the problem lies in the potential for the counselor to exploit clients or misuse power. Simply avoiding multiple relationships does not prevent exploitation. Counselors might deceive themselves into thinking that they cannot possibly exploit their clients if they avoid occupying more than one professional role. In reality, counselors can misuse their therapeutic power and influence in many ways and can exploit clients without engaging in dual or multiple relationships.
Some Dual or Multiple Relationships Are Unavoidable
It seems evident from the controversy over dual or multiple relationships that not all dual relationships can be avoided and that not all of these relationships are necessarily harmful or unethical. The APA (2010) states that “multiple relationships that would not reasonably be expected to cause impairment or risk exploitation or harm are not unethical” (3.05.a.). The key is to take steps to ensure that the practitioner’s judgment is not impaired and that no exploitation or harm to the client occurs.
Perhaps some of the clearest examples of situations in which dual relationships may be unavoidable occur in the lives of rural practitioners. In an isolated, rural community the local minister, merchant, banker, beautician, pharmacist, or mechanic might be clients of a particular counselor. In such a setting, the counselor may have to play several roles and is likely to find it more difficult to maintain clear boundaries than it is for colleagues who practice in more densely populated areas. It is worth noting that “small worlds” can exist in urban as well as in rural environments. In many close-knit communities, nonprofessional contacts and relationships are likely to occur because clients often seek out counselors who share their values and are familiar with their culture. These “small worlds” might include religious congregations, those in recovery from substance abuse, the gay/lesbian/bisexual/transgender community, some racial or ethnic minority groups, and the military.
The debate over dual or multiple relationships has been extensive, and much of it has been enlightening and thought provoking. At this point, we ask you to consider where you stand.
· What is your stance toward dual or multiple relationships?
· With which of the perspectives do you most agree?
· How did you arrive at this stance?
· What do you see as its risks and benefits?

Boundary Crossings Versus Boundary Violations
Some behaviors in which professionals may engage from time to time have a potential for creating a problematic situation, but these behaviors are not, by themselves, dual relationships. Some examples might be accepting a small gift from a client, accepting a client’s invitation to a special event such as a wedding, going out for coffee or tea with a client, making home visits to clients who are ill, or hugging a client at the end of a particularly painful session. Similar types of interactions are listed in the ACA Code of Ethics (ACA, 2014) as examples of “extending counseling boundaries” (Standard A.6.b.)
Some writers (Gabbard, 1995; Gutheil & Gabbard, 1993; R. I. Simon, 1992; Smith & Fitzpatrick, 1995) have suggested that such interactions might be considered boundary crossings rather than boundary violations. A boundary violation is a serious breach that results in exploitation or harm to clients. In contrast, a boundary crossing is a departure from commonly accepted practice that might benefit the client. Crossings occur when the boundary is shifted to respond to the needs of a particular client at a particular moment. Boundary crossings may even result in clinically effective interventions (Zur, 2012).
Interpersonal boundaries are not static and may be redefined over time as counselors and clients work closely together. Zur and Lazarus (2002) take the position that rigid boundaries are not in the best interests of clients. They maintain that rigidity, distance, and aloofness are in direct conflict with doing what is therapeutically helpful for clients. We agree with Zur and Lazarus’s thoughts on rigid boundaries, but we also believe that even seemingly innocent behaviors can lead to dual relationship entanglements with the potential for exploitation and harm if they become part of a pattern of blurring professional boundaries.
Some roles that professionals play involve an inherent duality. One such role is that of supervisor. Supervisees often experience an emergence of earlier psychological wounds and discover some of their own unfinished business as they become involved in working with clients. Ethical supervisors do not abandon their supervisory responsibilities by becoming counselors to supervisees, but they can encourage their supervisees to view personal therapy with another professional as a way to become more effective as a counselor and as a person. At the same time, although the supervisor and therapist roles differ, personal issues arise in both relationships, and supervisors need to give careful thought as to when and how these issues should be addressed. As another example, counselor educators serve as teachers, as therapeutic agents for student growth and self-awareness, as supervisors, and as evaluators, either sequentially or simultaneously. This role blending can present ethical dilemmas involving conflicts of interest or impaired judgments.
None of these roles or behaviors actually constitutes an ongoing dual relationship of the type that is likely to lead to sanctions by an ethics committee. Nonetheless, each does involve two individuals whose power positions are not equal. Role blending is not necessarily unethical, but it does require vigilance on the part of the professional to ensure that no exploitation occurs. One of the major difficulties in dealing with dual relationship issues is the lack of clear-cut boundaries between roles. Where exactly is the boundary between a counseling relationship and a friendship? How does a counselor educator remain sensitive to the need to promote student self-understanding without inappropriately acquiring personal knowledge about the student? Can a supervisor work effectively without addressing the supervisee’s personal concerns that may be impeding the supervisee’s performance? These are difficult questions, and any answers must include a consideration of the potential harm to clients, students, or supervisees when a dual relationship is initiated.
The Potential for Harm
Whatever the outcome of a dual or multiple relationship, a potential for harm almost always exists from the beginning of the relationship. To illustrate, let’s revisit the example given earlier of a behavior that was identified as benign or even therapeutic. No apparent harm was done when the marriage counselor attended the renewal of wedding vows ceremony and reception. But what might have happened if the counselor had simply accepted the invitation without discussing with the couple any potential problems that might arise? What if the counselor had been approached at the reception and asked how she knew the couple? Had the counselor answered honestly, she would have violated the privacy of the professional relationship. Had she lied or given an evasive answer, harm to the clients would have been avoided, but the counselor could hardly have felt good about herself as an honest and ethical person.
One of the major problems with multiple relationships is the possibility of exploiting the client (or student or supervisee). Kitchener and Harding (1990) contend that dual relationships lie along a continuum from those that are potentially very harmful to those with little potential for harm. They concluded that dual relationships should be entered into only when the risks of harm are small and when there are strong, offsetting ethical benefits for the client.
How does one assess the potential for harm? Kitchener and Harding identified three factors that counselors should consider: incompatibility of expectations on the part of the client, divergence of responsibilities for the counselor, and the power differential between the parties involved.
First, the greater the incompatibility of expectations in a dual role, the greater the risk of harm. For example, John, a supervisor, is also providing personal counseling to Suzanne, his supervisee. Although Suzanne understands that evaluation is part of the supervisory relationship, she places high value on the confidentiality of the counseling relationship. John is aware that her personal problems are impeding her performance as a counselor. In his supervisory role, he is expected to serve not only Suzanne’s interests but also those of the agency in which she is employed and of the public that she will eventually serve. When he shares his evaluations with her employer as his supervisory contract requires, and notes his reservations about her performance (without revealing the specific nature of her personal concerns), Suzanne feels hurt and betrayed. The supervisory behaviors to which she had agreed when she entered into supervision with John were in conflict with the expectations of confidentiality and acceptance that she had come to hold for John as her counselor.
Second, as the responsibilities associated with dual roles diverge, the potential for divided loyalties and loss of objectivity increases. When counselors also have personal, political, social, or business relationships with their clients, their self-interest may be involved and may compromise the client’s best interest. For example, Lynn is a counselor in private practice who has entered into a counseling relationship with Paula, even though she and Paula are partners in a small, part-time mail order business. In the counseling relationship, Paula reveals that she is considering returning to college, which means that she will have to give up her role in the business. Lynn is faced with divided loyalties because she does not want the business to fold and she does not have the time to take it over. As this example illustrates, it is difficult to put the client’s needs first when the counselor is also invested in meeting her own needs.
The third factor has to do with influence, power, and prestige. Clients, by virtue of their need for help, are in a dependent, less powerful, and more vulnerable position. For example, Darla is a counselor educator who is also counseling Joseph, a graduate student in the program. When a faculty committee meets to assess Joseph’s progress, Joseph is given probationary status because his work is marginal. Although Darla assures Joseph that she revealed nothing about his personal problems during the committee meeting, Joseph’s trust is destroyed. He is fearful of revealing his personal concerns in counseling with Darla because he knows that Darla will be involved in determining whether he will be allowed to continue his graduate studies at the end of his probationary period. He wants to switch to another counselor but is afraid of offending Darla. Counselor educators and counselors must be sensitive to the power and authority associated with their roles. They must resist using their power to manipulate students or clients. Because of the power differential, it is the professional’s responsibility to ensure that the more vulnerable individual in the relationship is not harmed.
Risks in Dual or Multiple Relationships
The potential for harm can translate into risks to all parties involved in a dual relationship. These risks can even extend to others not directly involved in the relationship.
Risks to Consumers
Of primary concern is the risk of harm to the consumer of counseling services. Clients who believe that they have been exploited in a dual relationship are bound to feel confused, hurt, and betrayed. This erosion of trust may have lasting consequences. These clients may be reluctant to seek help from other professionals in the future. Clients may be angry about being exploited but feel trapped in a dependence on the continuing relationship. Some clients, not clearly understanding the complex dynamics of a dual relationship, may feel guilty and wonder, “What did I do wrong?” Feelings of guilt and suppressed anger are potential outcomes when there is a power differential.
Students or supervisees, in particular, may be aware of the inappropriateness of their dual relationships yet feel that the risks are unacceptably high in confronting a professional who is also their professor or supervisor. Any of these feelings—hurt, confusion, betrayal, guilt, anger—if left unresolved could lead to depression and helplessness, the antitheses of desired counseling outcomes.
Risks to the Professional
Risks to the professional who becomes involved in a dual relationship include damage to the therapeutic relationship and, if the relationship comes to light, loss of professional credibility, charges of violations of ethical standards, suspension or revocation of license or certification, and risk of malpractice litigation. Malpractice actions against therapists are a risk when dual relationships have caused harm to the client, and the chances of such a suit being successful increase if the therapist cannot provide sound clinical justification and demonstrate that such practices are within an accepted standard of care.
Many dual or multiple relationships go undetected or unreported and never become the subject of an inquiry by an ethics committee, licensure board, or court. Nonetheless, these relationships do have an effect on the professionals involved, causing them to question their competence and diminishing their sense of moral self-hood.
Effects on Other Consumers
Dual or multiple relationships can create a ripple effect, affecting even those who are not directly involved in the relationship. This is particularly true in college counseling centers, schools, hospitals, counselor education programs, or any other relatively closed system in which other clients or students have opportunities to be aware of a dual relationship. Other clients might well resent that one client has been singled out for a special relationship. This same consideration is true in dual relationships with students and supervisees. Because a power differential is also built into the system, this resentment may be coupled with a reluctance to question the dual relationship openly for fear of reprisal. Even independent private practitioners can be subject to the ripple effect. Former clients are typically a major source of referrals. A client who has been involved in a dual relationship and who leaves that relationship feeling confused, hurt, or betrayed is not likely to recommend the counselor to friends, relatives, or colleagues.
Effects on Other Professionals
Fellow professionals who are aware of a dual or multiple relationship are placed in a difficult position. Confronting a colleague is always uncomfortable, but it is equally uncomfortable to condone the behavior through silence. This creates a distressing dilemma that can undermine the morale of any agency, center, hospital, or other system in which it occurs. Paraprofessionals or others who work in the system and who are less familiar with professional codes of ethics may be misled and develop an unfortunate impression regarding the standards of the profession.
Effects on the Profession and Society
The counseling profession itself is damaged by the unethical conduct of its members. As professionals, we have an obligation both to avoid causing harm in dual relationships and to act to prevent others from doing harm. If we fail to assume these responsibilities, our professional credibility is eroded, regulatory agencies will intervene, potential clients will be reluctant to seek counseling assistance, and fewer competent and ethical individuals will enter counselor training programs. Conscientious professionals need to remain aware not only of the potential harm to consumers but also of the ripple effect that extends the potential for harm.
Safeguards to Minimize Risks
Whenever we as professionals are operating in more than one role, and when there is potential for negative consequences, it is our responsibility to develop safeguards and measures to reduce (if not eliminate) the potential for harm. These guidelines include the following:
· Set healthy boundaries from the outset. It is a good idea for counselors to have in their professional disclosure statements or informed consent documents a description of their policy pertaining to professional versus personal, social, or business relationships. This written statement can serve as a springboard for discussion and clarification.
· Involve the client in setting the boundaries of the professional or nonprofessional relationship. Although the ultimate responsibility for avoiding problematic dual relationships rests with the professional, clients can be active partners in discussing and clarifying the nature of the relationship. It is helpful to discuss with clients what you expect of them and what they might expect of you.
· Informed consent needs to occur at the beginning of and throughout the relationship. If potential dual relationship problems arise during the counseling relationship, these should be discussed in a frank and open manner. Clients have a right to be informed about any possible risks.
· Practitioners who are involved in unavoidable dual relationships or nonprofessional relationships need to keep in mind that, despite informed consent and discussion of potential risks at the outset, unforeseen problems and conflicts can arise. Discussion and clarification may need to be an ongoing process.
· Consultation with fellow professionals can be useful in getting an objective perspective and identifying unanticipated difficulties. We encourage periodic consultation as a routine practice for professionals who are engaged in dual relationships. We also want to emphasize the importance of consulting with colleagues who hold divergent views, not just those who tend to support our own perspectives.
· When dual or multiple relationships are particularly problematic, or when the risk for harm is high, practitioners are advised to work under supervision.
· Counselor educators and supervisors can talk with students and supervisees about balance of power issues, boundary concerns, appropriate limits, purposes of the relationship, potential for abusing power, and subtle ways that harm can result from engaging in different and sometimes conflicting roles.
· Professionals are wise to document any dual relationships in their clinical case notes, more as a legal than as an ethical precaution. In particular, it is a good idea to keep a record of any actions taken to minimize the risk of harm.
· If necessary, refer the client to another professional.
Some Gray Areas
Although the ACA Code of Ethics (ACA, 2014) expressly forbids sexual or romantic relationships with clients or former clients, counseling close friends or family members, and engaging in personal virtual relationships with current clients, many “gray areas” remain. Do social relationships necessarily interfere with a therapeutic relationship? Some would say that counselors and clients can handle such relationships as long as the priorities are clear. For example, some peer counselors believe friendships before or during counseling are positive factors in building cohesion and trust. Others take the position that counseling and friendships do not mix well. They claim that attempting to manage a social and a professional relationship simultaneously can have a negative effect on the therapeutic process, the friendship, or both.
What about socializing with former clients, or developing a friendship with former clients? Although mental health professionals are not legally or ethically prohibited from entering into a nonsexual relationship with a client after the termination of therapy, the practice could lead to difficulties for both client and counselor. The imbalance of power may change very slowly, or not at all. Counselors should be aware of their own motivations, as well as the motivations of their clients, when allowing a professional relationship to eventually evolve into a personal one, even after termination. When all things are considered, it is probably wise to avoid socializing with former clients.
Another relationship-oriented question relates to the appropriate limits of counselor self-disclosure with clients. Although some therapist self-disclosure can facilitate the therapeutic process, excessive or inappropriate self-disclosure can have a negative effect.
A final related issue has to do with gifts. When is it appropriate or inappropriate to accept a gift that a client has offered? These questions are explored in the following sections.
Counseling a Friend or Acquaintance
Many writers have cautioned against counseling a friend, and the ACA Code of Ethics (ACA, 2014) expressly prohibits counseling close friends. Kitchener and Harding (1990) point out that counseling relationships and friendships differ in function and purpose. We agree that the roles of counselor and friend are incompatible. Friends do not pay their friends a fee for listening and caring. It will be difficult for a counselor who is also a friend to avoid crossing the line between empathy and sympathy. It hurts to see a friend in pain. Because a dual relationship is created, it is possible that one of the relationships—professional or personal—will be compromised. It may be difficult for the counselor to confront the client in therapy for fear of damaging the friendship. It is also problematic for clients, who may hesitate to talk about deeper struggles for fear that their counselor/friend will lose respect for them. Counselors who are tempted to enter into a counseling relationship with a friend would do well to ask themselves whether they are willing to risk losing the friendship.
A question remains, however, as to where to draw the line. Is it ethical to counsel a mere acquaintance? A friend of a friend? A relative of a friend? We think it is going to absurd lengths to insist that counselors have no other relationship, prior or simultaneous, with their clients. Often clients seek us out for the very reason that we are not complete strangers. A client may have been referred by a mutual friend or might have attended a seminar given by the counselor. A number of factors may enter into the decision as to whether to counsel someone we know only slightly or indirectly.
Borys (1988) found that male therapists, therapists who lived and worked in small towns, and therapists with 30 or more years of experience all rated remote dual professional roles (as in counseling a client’s friend, relative, or lover) as significantly more ethical than did a comparison group. Borys speculated that men and women receive different socialization regarding the appropriateness of intruding on or altering boundaries with the opposite sex: Men are given greater permission to take the initiative or otherwise become more socially intimate. In a rural environment or a small town, it is difficult to avoid other relationships with clients who are likely to be one’s banker, beautician, store clerk, or plumber. Perhaps more experienced therapists believe they have the professional maturity to handle dualities, or it could be that they received their training at a time when dual relationships were not the focus of much attention in counselor education programs. Whatever one’s gender, work setting, or experience level, these boundary questions will arise for counselors who conduct their business and social lives in the same community.
A good question to ask is whether the nonprofessional relationship is likely to interfere, at some point, with the professional relationship. Sound professional judgment is needed to assess whether objectivity can be maintained and role conflicts avoided. Yet we need to be careful not to place too much value on “objectivity.” Being objective does not imply a lack of personal caring or subjective involvement. Although it is true that we do not want to get lost in the client’s world, we do need to enter this world to be effective.
A special kind of dual relationship dilemma can arise when a counselor needs counseling. Therapists are people, too, and have their own problems. Many of us will want to talk to our friends, who might be therapists, to help us sort out our problems. Our friends can be present for us in times of need and provide compassion and caring, although not in a formal therapeutic way. We will not expect to obtain long-term therapy with a friend, nor should we put our friends in a difficult position by requesting such therapy.
A related boundary consideration is how to deal with clients who want to become our friends via the Internet. It is not unusual for a counselor to receive a “Friend Request” from a client or former client. For counselors who are considering using Facebook, a host of ethical concerns about boundaries, dual relationships, and privacy are raised. Spotts-De Lazzer (2012) claims that practitioners will have to translate and maintain traditional ethics when it comes to social media. Spotts-De Lazzer offers these recommendations to help counselors manage their presence on Facebook:
· Limit what is shared online.
· Include clear and thorough social networking policies as part of the informed consent process.
· Regularly update protective settings because Facebook options are constantly changing.
Zur and Zur (2011) have outlined a number of questions therapists should reflect on before agreeing to become involved as a friend on Facebook or some other form of social media. Some of these questions include:
· What is on the Facebook profile?
· What is the context of counseling?
· Who is the client, and what is the nature of the therapeutic relationship?
· Why did the client post the request?
· What is the meaning of the request?
· Where is the counseling taking place?
· What does being a “Friend” with this client mean for the therapist and for the client?
· What are the ramifications of accepting a Friend Request from a client for confidentiality, privacy, and record keeping?
· Does accepting a Friend Request from a client constitute a dual relationship?
· How will accepting the request affect treatment and the therapeutic relationship?
As is evident by considering this list of questions, the issue of whether or not to accept a client’s Friend Request is quite complex and requires careful reflection and consultation. To read more about this topic, visit the Zur Institute at
http://www.zurinstitute.com/
.
Socializing With Current Clients
Socializing with current clients may be an example of a boundary crossing if it occurs inadvertently or infrequently or of an inappropriate dual relationship, depending on the nature of the socializing. A social relationship can easily complicate keeping a therapeutic relationship on course. Caution is recommended when it comes to establishing social relationships with former clients, and increased caution is needed before blending social and professional relationships with current clients. Among Borys’s (1988) findings were that 92% of respondents believed that it was never or only rarely ethical to invite clients to a personal party or social event; 81% gave these negative ratings to going out to eat with a client after a session. Respondents felt less strongly about inviting clients to an office or clinic open house (51% viewed this as never or rarely ethical) or accepting a client’s invitation to a special occasion (33%).
One important factor in determining how therapists perceive social relationships with clients may be their theoretical orientation. Borys found psychodynamic practitioners to be the most concerned about maintaining professional boundaries. One reason given for these practitioners’ opposition to dual role behaviors was that their training promotes greater awareness of the importance of clear, nonexploitive, and therapeutically oriented roles and boundaries. In the psychodynamic view, transference phenomena give additional meaning to alterations in boundaries for both client and therapist. A further explanation is that psychodynamic theory and supervision stress an informed and scrupulous awareness of the role the therapist plays in the psychological life of the client—namely, the importance of “maintaining the frame of therapy.”
A counselor’s stance toward socializing with clients appears to depend on several factors. One is the nature of the social function. It may be more acceptable to attend a client’s special event such as a wedding than to invite a client to a party at the counselor’s home. The orientation of the practitioner is also a factor to consider. Some relationship-oriented therapists might be willing to attend a client’s graduation party, for instance, but a psychoanalytic practitioner might feel uncomfortable accepting an invitation for any out of the office social function. This illustrates how difficult it is to come up with blanket policies to cover all situations.
· What are your views about socializing with current clients?
· Do you think your theoretical orientation influences your views?
· Under what circumstances might you have contact with a client out of the office?

Social Relationships With Former Clients
Having considered the matter of socializing with current clients, we now look at posttermination social relationships between counselors and clients. Few professional codes specifically mention social relationships with former clients. An exception is the Canadian Counselling and Psychotherapy Association (2007) code of ethics:
Counsellors remain accountable for any relationships established with former clients. Those relationships could include, but are not limited to those of a friendship, social, financial, and business nature. Counsellors exercise caution about entering any such relationships and take into account whether or not the issues and relational dynamics present during the counselling have been fully resolved and properly terminated. In any case, counsellors seek consultation on such decisions. (B.11.)
In the first edition of this book, we noted that Kitchener (1992) described the nature of the relationship once the therapeutic contract has been terminated as one of the most confusing issues for counselors and their clients. Clients may fantasize that their counselors will somehow remain a significant part of their lives as surrogate parents or friends. Counselors are sometimes ambivalent about the possibility of continuing a relationship because they are aware of real attributes of clients that under other circumstances might make them desirable friends, colleagues, or peers.
Nonetheless, there are real risks that need to be considered. Studies have suggested that memories of the therapeutic relationship remain important to clients for extended periods after termination and that many clients consider reentering therapy with their former therapists (Vasquez, 1991). This reentry option is closed if other relationships have ensued. Kitchener (1992) maintains that the welfare of the former client and the gains that have been made in counseling are put at risk when new relationships are added to the former therapeutic one. Kitchener suggests that many of the same dynamics may be operating in nonsexual posttherapy relationships as in sexual ones, although not at the same level of emotional intensity. Her conclusion is that counselors should approach the question of posttherapy relationships with care and with awareness of their strong ethical responsibility to avoid undoing what they and their clients have worked so hard to accomplish.
Two studies reveal that there is little consensus among therapists regarding whether nonromantic relationships between therapists and former clients are ethical. The majority of the participants in a study by Anderson and Kitchener (1996) did not hold to the concept of “once a client, always a client” with respect to nonsexual posttherapy relationships. Some participants suggested that posttherapy relationships were ethical if a certain time period had elapsed. Others proposed that such relationships were ethical if the former client decided not to return to therapy with the former therapist and if the posttherapy relationship did not seem to hinder later therapy with different therapists.
Another study by Salisbury and Kinnier (1996) found similar results regarding counselors’ behaviors and attitudes regarding friendships with former clients. The major finding was that many counselors are engaged in posttermination friendships and believe that under certain circumstances such relationships are acceptable. Seventy percent of the counselors believed that posttermination friendships were ethical approximately 2 years after termination of the professional relationship. Although most codes of ethics now specify a minimum waiting period for sexual relationships with former clients, the codes do not address the issue of friendships with former clients.
In reviewing the codes of ethics of the various professional organizations, it appears that entering into social relationships with former clients is not considered unethical, yet the practice could become problematic. The safest policy is probably to avoid developing social relationships with former clients. Even after the termination of a therapeutic relationship, former clients may need or want our professional services at some future time, which would be ruled out if a social relationship has been established.
· What are your thoughts about social relationships with former clients?
· Do you think codes of ethics should specifically address nonromantic and nonsexual posttherapy relationships?
· Under what circumstances might such relationships be unethical?
· When might you consider them to be ethical?

A Contributor’s Perspective
Ed Neukrug presents a personal perspective on a study he and a colleague conducted in 2011 on counselors’ perceptions of ethical and unethical behaviors. Participants rated 77 behaviors, and many of these behaviors pertained to boundary issues.
Making Ethical Decisions When Faced With Thorny Boundary Issues

Ed Neukrug

In 1993 Gibson and Pope published the results of a study that asked counselors to identify whether they believed 88 counselor behaviors were ethical or unethical. The questions highlighted the kinds of behaviors with which counselors struggle, and I included the results in two editions of my book The World of the Counselor (Neukrug, 2012). In 2011, with the fourth edition of the book ready to be written, I realized that a 1993 study was a bit old. Fascinated with the original research, I decided to update the study with a colleague of mine. In 2011 the new study was published, and soon after I added the results to the new edition of my book.
The updated version of the study identified 77 behaviors (see Neukrug & Milliken, 2011). Although we kept some of the original items from the Gibson and Pope study, we did not include items for which there had been close to 100% agreement by counselors in the original study. For instance, we did not ask if it was ethical to have sex with clients or to work while drunk. In the original study, just about every counselor felt strongly that those behaviors were unethical, and we knew from years of teaching that counselors had a clear understanding that behaviors such as these were unethical. We wanted to make sure the new survey reflected current codes. For instance, since 1993 the ACA Code of Ethics has twice been revised, with the latest Code replacing the term clear and eminent danger with serious and foreseeable harm; increasing restrictions on romantic and sexual relationships; including a statement on the permissibility of end-of-life counseling for terminally ill clients; increasing attention to social and cultural issues; allowing counselors to refrain from making a diagnosis; highlighting the importance of having a scientific basis for treatment; requiring counselors to have a transfer plan for clients; adding technology guidelines; including a statement about the right to confidentiality for deceased clients; and softening the permissibility of dual relationships, now often referred to as multiple relationships (ACA, 2005; Kaplan et al., 2009).
The new survey kept about one third of the original items, revised about one third of the original items, and included about one third new items that reflected changes since 1993. The new survey asked counselors to identify whether each of the 77 counselor behaviors were ethical or not ethical and to rate each counselor behavior on a 10-point Likert-type scale indicating how strongly they felt about their responses (1 = not very strongly, 10 = very strongly). In addition, the new survey asked counselors whether they had received ethics training in their program or elsewhere. Here we found some interesting results compared to the Gibson and Pope (1993) study.
Whereas Gibson and Pope found 73% of respondents had ethics training, a resounding 97.8% of counselors in our survey stated they had ethics training. Similarly, whereas 29% of counselors in the Gibson and Pope study reported taking a formal ethics course, this study found 60% had taken one ethics course, and 60% had taken more than one ethics course. In addition, a similar number stated that ethics training was infused throughout their program. The increase in ethics training demonstrates a major shift nationally and is likely the result of a number of changes. For instance, the increase in the number of programs accredited by the Council for Accreditation of Counseling and Related Educational Programs (CACREP) has undoubtedly affected these statistics because CACREP requires students to learn about ethics (CACREP, 2009; Urofsky & Sowa, 2004). This growth in ethics training is probably also the result of credentialing boards increasingly requiring ethics training when professionals obtain or renew their credentials (National Board for Certified Counselors, 2012). Also, as society has become increasingly litigious, the importance of ethics training to avoid malpractice lawsuits has become paramount (Neukrug, Milliken, & Walden, 2001; Remley & Herlihy, 2014; Saunders, Barros-Bailey, Rudman, Dew, & Garcia, 2007). Finally, this greater focus on ethics training has probably fostered a surge in scholarly materials (e.g., journal articles) that increase knowledge of ethics among professionals.
Counselor Perceptions of Boundary Crossings
There is an expectation placed on counselors to maintain the sanctity of the counseling relationship by maintaining boundaries between themselves and the clients they serve (Remley & Herlihy, 2014). Our ethics codes tend to support this perspective, highlighting behaviors that should be avoided to protect our clients from injury. Our professional associations expect counselors to exhibit certain behaviors that respect boundaries between counselors and clients, and clients generally have a fairly good sense of what is “right and wrong” within the relationship regarding boundaries. Of course, it helps if clients have a clear understanding of these boundaries, and counselors can provide clients with an informed consent statement that addresses issues of boundaries in the relationship and the ethics code from the counselor’s professional association.
Despite expectations from our professional associations and dictates from our ethics codes, many boundary issues are complicated, and, as noted earlier in the chapter, sometimes an intentional and thoughtful boundary crossing can be helpful to the counseling relationship (G. Corey et al., 2015; Moleski & Kiselica, 2005; Zur, 2007). Although our survey examined counselors’ beliefs regarding a wide range of behaviors, a number of items specifically addressed boundary issues, the focus of this book. We have teased out those items and present them in
Table 1.1
. For the complete study results, see Neukrug and Milliken (2011).

Table 1.1
Counselors′ Perceptions Regarding Boundary Issues

Percentage

Strength of Response

Item Number and Behavior

Ethical

Unethical

1. Breaking confidentiality if the client is threatening harm to self

95.7

4.3

8.73

3.6

2. Having clients address you by your first name

94.9

5.1

7.41

3.9

3. Using an interpreter when a client’s primary language is different from yours

88.8

11.2

5.4

5.0

4. Self-disclosing to a client

86.8

13.2

4.4

4.7

5. Consoling your client by touching him or her (e.g., placing your hand on his or her shoulder)

83.9

16.1

4.5

5.2

6. Publicly advocating for a controversial cause

83.6

16.4

4.2

5.4

7. Attending a client’s wedding, graduation ceremony, or other formal ceremony

72.1

27.9

2.2

5.8

8. Hugging a client

66.7)

33.3

1.7

5.5

9. Counseling a pregnant teenager without parental consent

62.0

38.0

1.5

6.7

10. Telling your client you are angry at him or her

61.5

38.5

1.0

6.7

11. Withholding information about a minor client despite a parent’s request for information

47.4

52.6

−0.7

6.8

12. Pressuring a client to receive needed services

43.3

56.7

−0.9

6.4

13. Becoming sexually involved with a former client (at least 5 years after the counseling relationship ended)

42.9

57.1

−2.1

6.8

14. Guaranteeing confidentiality for group members

36.9

63.1

−2.1

7.5

15. Sharing confidential client information with a colleague who is not your supervisor

29.4

70.6

−3.5

6.7

16. Engaging in a helping relationship with a client (e.g., individual counseling) while the client is in another helping relationship (e.g., family counseling) without contacting the other counselor

26.8

73.2

−4.0

6.2

17. Seeing a minor client without parental consent

25.4

74.6

−4.3

6.2

18. Viewing your client’s personal Web page (e.g., MySpace, Facebook, blog) without informing your client

22.5

77.5

−4.7

5.8

19. Becoming sexually involved with a person your client knows well

22.3

77.7

−5.1

5.9

20. Trying to change your client’s values

13.4

86.6

−6.5

5.3

21. Kissing a client as a friendly gesture (e.g., greeting)

12.5

87.5

−6.6

4.6

22. Accepting a gift worth more than $25 from a client

11.7

88.3

−6.1

4.6

23. Revealing confidential information if a client is deceased

11.6

88.4

−6.0

4.5

24. Engaging in a professional counseling relationship with a colleague who works with you

10.7

89.3

−7.8

3.7

25. Engaging in a dual relationship (e.g., your client is also your child’s teacher)

10.4

89.6

−6.6

4.6

26. Telling your client you are attracted to him or her

10.3

89.7

−7.6

4.6

27. Giving a gift worth more than $25 to a client

5.3

94.7

−7.5

3.7

28. Engaging in a professional counseling relationship with a friend

4.6

95.4

−7.8

3.6

29. Lending money to your client

3.4

96.6

−8.3

3.1

30. Revealing a client’s record to the spouse of a client without the client’s permission

0.6

99.4

−9.2

2.1

31. Attempting to persuade your client to adopt a religious conviction you hold

0.6

99.4

−9.2

2.0

Context Is Everything
In reviewing
Table 1.1
, it is clear that many counselors believe certain behaviors to be acceptable even though they will affect the boundary between counselor and client. For instance, more than 85% of counselors believed these behaviors are ethical: “breaking confidentiality if the client is threatening harm to self,” “having clients address you by your first name,” “using an interpreter when a client’s primary language is different from yours,” and “self-disclosing to a client.” However, even when the vast majority of counselors believe a behavior to be ethical, their actual responses may vary dramatically as a function of the context. For instance, a counselor doesn’t break confidentiality in all cases of potential “harm to self.” Rather, the decision depends on the seriousness of the thoughts, the likelihood of the action, and the means available to the client. Similarly, although many counselors may feel comfortable having clients address them by their first names, in some cases, depending on the professional style of the counselor or the issues of the client (a client who has boundary issues in his or her life), a counselor may decide it is important for a client to not address the counselor by his or her first name. Although it may be acceptable and even important to use an interpreter in a counseling relationship, a counselor must consider whether the interpreter is trustworthy and can keep the conversation confidential and how the use of an interpreter might affect the willingness of the client to discuss embarrassing or shameful material. It may be better to refer this client to a person who speaks the client’s language. Finally, although incidental self-disclosures such as “I’m so proud of you” or “I love your outfit today” can add to the working alliance, we are all aware that inappropriate self-disclosures that reveal too much about the counselor, or are done for the wrong reasons, can wreak havoc in the helping relationship.
Similarly, most counselors believe a number of behaviors are unethical most of the time and would negatively affect the boundary within the helping relationship if practiced. But even here context is everything, and a counselor might decide to exhibit the behavior in certain circumstances. Consider the following behaviors from
Table 1.1
that most counselors view as unethical. Then look at the corresponding counselor situation in which exhibiting such a behavior might be acceptable.
1. Item 20: Trying to change your client’s values
1. A counselor working with a client who uses corporal punishment suggests other ways that the client can parent, shows her “positive parenting” techniques, and points out the research regarding the effectiveness of positive parenting and the ineffectiveness of corporal punishment.
2. Item 21: Kissing a client as a friendly gesture (e.g., greeting)
1. A counselor and client share a cultural heritage in which a kiss on the cheek is usual and expected.
3. Item 22: Accepting a gift worth more than $25 from a client
1. A client who is terminating counseling after years of work with a counselor gives the counselor a $30 book as a thank-you for their work together.
4. Item 24: Engaging in a professional counseling relationship with a colleague who works with you
1. The only counselor in an area practicing a neuroprocessing technique to relieve stress migraines is asked by a coworker to work with him for the three sessions needed to learn the process.
5. Item 25: Engaging in a dual relationship (e.g., your client is also your child’s teacher)
1. A new client comes to counseling and the counselor realizes that the two of them are in the same exercise class. Together, they decide they can manage the dual relationship.
6. Item 26: Telling your client you are attracted to him or her
1. Having worked with a depressed client for a while who has recently made some significant changes, a counselor says, “You have such an attractive smile when your depression lifts.”
7. Item 27: Giving a gift worth more than $25 to a client
1. A client with whom you have worked has focused on improving her life. One area in which she has worked long and hard is obtaining her general equivalency diploma (GED). After 2 years of hard work, she obtains her GED. You decide to have her diploma framed as a reinforcement of her hard work.
Reflecting on Context
Despite the fact that the behaviors just discussed were seen as mostly ethical (Items 1–5) or mostly unethical (Items 20–27) by the vast majority of counselors, responses can still vary as a function of context. In our survey, counselors had a fair amount of disagreement regarding whether some items were ethical or unethical (Items 5–19). These behaviors represent situations in which counselors might struggle. Keeping context in mind, review these behaviors and consider when you believe it might be appropriate or inappropriate to exhibit the behaviors. Finally, you might also want to tackle the last four items (Items 28–31) and consider whether there is ever a time when such behaviors might be ethical.
Ethical decision making around boundary issues can be a complex and difficult process, and responses may not always be as obvious as we might expect. Knowing your client, yourself, and the context of the particular ethical dilemma can help you make a wise decision in the client’s best interests.

A Contributor’s Perspective
Arnold A. Lazarus presents a provocative argument that strict boundary regulations may have a negative impact on therapeutic outcomes. He encourages therapists to avoid practicing defensively and to be willing to think and venture outside the proverbial box.
Transcending Boundaries in Psychotherapy

Arnold A. Lazarus

When I was an undergraduate student in South Africa (1951–1955), the dominant ethos was Freudian psychoanalysis. Most of the books and articles we read were authored by Freud or his followers. Practitioners endeavored to remain a “blank screen” to their patients or “analysands.” They avoided any self-disclosures, and all communications were strictly confined to the office or consulting room, which contained nothing personal—no diplomas, no family photos—and the only furniture was a couch, a desk, and some chairs. For the analyst to become the “screen” on which the patient projects fantasies and feelings during the transference process, he or she remains passive and neutral. This permits the patient to feel free to voice his or her private and innermost ideas and attitudes without interference by the personality of the analyst.
Some of the practitioners were so rigid that if they walked into a restaurant and saw one of their analysands they would leave immediately. Even when the field became more eclectic, many analytic proscriptions and prohibitions spilled over and were adopted by most therapists. Subsequently, when rules of ethics were first drawn up, any form of fraternization with a client was frowned upon, and dual relationships were considered taboo. During my internship in 1957 two of my peers were severely reprimanded: one for sharing tea and cookies with a client, and the other for helping a woman on with her coat.
As my orientation became behavioral and the theories and methods I applied differed significantly from psychoanalytic and psychodynamic approaches, I argued that there was no need to subscribe to their rules of client–therapist interaction. Far from being a “screen,” I was a fellow human being who considered it important to treat clients with dignity, respect, decency, and equality. Indeed, “breaking bread” with some clients fostered closer rapport, as did some out-of-office experiences such as driving a client to the train station on a cold rainy day. It always struck me as very impolite, if not insulting, to answer a question with a question instead of answering the question and then inquiring why that issue had been raised. One of my clients complained that when he asked his psychodynamic therapist a noninvasive and not too personal question she said, “We are not here to discuss me.” He said he felt demeaned and terminated the therapy soon thereafter.
To balance the playing field, it is necessary to remember that most rules have exceptions, and it is essential to observe certain caveats. There are clients with whom clear-cut boundaries are necessary. People who fit into certain diagnostic categories or evince certain behaviors require a definite structure and clear-cut boundaries: for example, those with psychoses, bipolar depression, borderline personalities, antisocial tendencies, substance abuse, histrionic personality disorders, character pathology, suicidal behaviors, eating disorders (especially anorexia nervosa), self-injurious behaviors, or criminal proclivities. A definite structure and clear-cut boundaries are not an invitation to mete out or exhibit nonempathic behavior, impolite comments, judgmental statements, or insulting remarks. The reason I am underscoring these issues is because many people have erroneously concluded that I am advocating a laissez-faire and capricious fraternization with all clients. It is necessary to be wary and well informed before deciding that it would be in the client’s best interests to stretch or cross certain boundaries. I am opposed to clinicians who treat all their clients in the same way and always go by the book. I reiterate that while deciding whether or not to traverse demarcated boundaries, if one has any misgivings, it is best to err on the side of caution.
A prevalent practice that tends to handicap therapists and often leads them to harm rather than to help certain clients or patients is therapists’ insistence on maintaining strict boundaries. They practice defensively, guided by their fear of licensing boards and attorneys rather than by clinical considerations. Risk management seminars typically warn therapists that if they cross boundaries severely negative consequences from licensing boards and ethics committees are likely to ensue. For example, they are warned not to fraternize or socialize with clients and are told to steer clear of any mutual business transactions (other than the fee for service). They are advised to avoid bartering and to avoid working with or seeing a client outside the office. Yet those therapists who transcend certain boundaries with selected clients often provide superior help. They rely on their own judgment and refuse to hide behind barriers or to function within a metaphorical straitjacket. Great benefits can accrue when therapists are willing to think and venture outside the proverbial box. Here is a case in point.
Paul, aged 17, required help for some potentially serious drug problems. His parents had tried to find a therapist who could treat and assist him, but to no avail. Paul had initial meetings with four different therapists over a 6-week interval but declared each one “a jerk” and refused to go back. He then reluctantly consulted a fifth therapist (who had been one of my recent postdoctoral students) who quickly sized up the situation. He realized that Paul would regard any formal meeting with a professional therapist as reminiscent of his uptight parents and strict teachers, so he would resist their ministrations. The therapist cleverly stepped out of role and invited Paul to shoot some baskets with him later that day at a nearby basketball court. It took several weeks of basketball playing and informal chatting before adequate rapport and trust were established, at which point Paul was willing to engage in formal office visits and seriously address his problems.
This innovative, free-thinking, and creative therapist was willing to take a risk and cross a boundary, and in so doing he gained the trust of a young man who was really hurting emotionally. This enabled Paul to respond to the therapist as a kind and accomplished big brother he could look up to and from whom he could learn a good deal.
Why have psychotherapists found it necessary to form ethics committees; establish a wide range of principled dos and don’ts; and police, discipline, and penalize those who cross the line? This is probably in response to the extreme laissez-faire climate of therapeutic interaction that prevailed in the 1950s and 1960s, when blatant boundary crossings were openly espoused. For example, at Esalen in California, where Frederick (Fritz) Perls and his associates established a training and therapy institute, therapists and clients often became playmates and even lovers. It is not far fetched to look upon many of their dealings as flagrant acts of malpractice. Concerned professionals became aware of the emotional damage that was being wrought in many settings and sought to establish a code of ethics and to lay down basic ground rules for practitioners. Terms like boundaries, boundary violation, and standard of care entered the vernacular.
Today, all therapists are expected to treat their clients with respect, dignity, and consideration and to adhere to the spoken and unspoken rules that make up our established standards of care. Many of these rules are necessary and sensible. For instance, it is essential for therapists to avoid any form of exploitation, harassment, harm, or discrimination, and it is understandable that a sexual relationship with a client is considered an ultimate taboo. Emphasis is placed on the significance of respect, integrity, confidentiality, and informed consent. Nevertheless, some elements of our ethics codes have become so needlessly stringent and rigid that they can undermine effective therapy. The pendulum has swung too far in the opposite direction from the era of negligent free-for-all indulgence.
One of my major concerns is that there is a widespread failure to grasp the critical difference between “boundary violations,” which can harm a client, and “boundary crossings,” which produce no harm and may even enhance the therapeutic connection. For example, what would be so appalling about a therapist saying to a client who has just been seen from 11 a.m. until noon: “We seem to be onto something important. Should we go and pick up some sandwiches at the local deli, and continue until 1 p.m. at no extra fee to you?” Strict boundary proponents would regard such behavior as unethical because it goes outside the therapeutic frame. However, strategic therapists would argue that rigid adherence to a particular frame and setting only exacerbates problems, especially in nonresponsive patients. For example, a patient of mine who had been resistant and rather hostile arrived early for his appointment. I was just finishing lunch and had some extra sandwiches on hand, so I offered him one. He accepted my offer as well as a glass of orange juice. Coincidentally or otherwise, thereafter our rapport was greatly enhanced, and he made significant progress. What became clear during our ensuing sessions was that the act of literally breaking bread led him to perceive me as humane and caring and facilitated his trust in me.
Over the past 40 years, I have seen thousands of clients and have selectively transcended boundaries on many occasions. For example, I engaged in barter with an auto mechanic, who tuned my car in exchange for three therapy sessions. I have accepted dinner invitations from some clients, have attended social functions with others, played tennis with several clients, and ended up becoming good friends with a few. Of course, I do not engage in such behaviors capriciously. Roles and expectations must be clear. Possible power differentials must be kept in mind. For my own protection as well as the client’s protection, I don’t engage in these behaviors with seriously disturbed people, especially those who are hostile, paranoid, aggressive, or manipulative. But the antiseptic obsession with “risk management” has led far too many therapists to practice their craft in a manner that is needlessly constraining and often countertherapeutic.
Those therapists who rigidly adhere to strict professional boundaries are apt to place risk management ahead of humane interventions. The manner in which they speak to their clients often leaves much to be desired. For example, I recently attended a clinical meeting at which a young psychiatrist was interviewing a woman who suffered from an eating disorder, bulimia nervosa. At one point the dialogue continued more or less as follows:
1. Patient: May I ask how old you are?
2. Therapist: Why is that important?
3. Patient: It’s no big deal. I was just curious.
4. Therapist: Why would you be curious about my age?
5. Patient: Well, you look around 30, and I was just wondering if I am correct.
6. Therapist: What impact would it have if you were not correct?
7. Patient: None that I can think of. It was just idle curiosity.
8. Therapist: Just idle curiosity?
As I watched these exchanges, I grew uncomfortable. It seemed to me that the patient wished she had never raised the issue in the first place and that she was feeling more and more uneasy. It did not seem that the dialogue was fostering warmth, trust, or rapport. On the contrary, it resembled a cross-examination in a courtroom and appeared adversarial.
In psychoanalysis it is deemed important for the analyst to remain neutral and nondisclosing so the patient can project his or her needs, wishes, and fantasies onto a “blank screen.” But it makes no sense for this to become a rule for all therapists to follow. It has always struck me as ill mannered and discourteous to treat people this way.
I recommend the following type of exchange in place of the aforementioned example:
1. Patient: How old are you?
2. Therapist: I just turned 30. Why do you ask?
3. Patient: I was just curious. It’s no big deal.
4. Therapist: Might you be more comfortable with or have greater confidence in someone younger or older?
5. Patient: No, not at all.
At this juncture, I would suggest that the topic be dropped. Notice the recommended format. First answer the question and then proceed with an inquiry if necessary. In this way, the patient is validated and not demeaned. Why am I dwelling on such a seemingly trivial issue? Because it is not a minor or frivolous point, and I have observed this type of interaction far too often, usually to the detriment of the therapeutic process. I see it as part and parcel of a dehumanizing penchant among the many rigid thinkers in our field who legislate against all boundary extensions. These are the members of our profession (and they are not a minority) who regard themselves as superior to patients and tend to infantilize and demean them in the process.
The purpose of this essay is to alert readers to an issue that is crucial in the field of psychotherapy. I have coedited a book (Lazarus & Zur, 2002) on the subject of boundaries and boundary crossings in which various contributors have addressed the topic from many viewpoints: nonanalytic practice procedures, feminist perspectives, military psychology, counseling centers, deaf communities, legal issues, gay communities, and rural settings (among others). It is generally agreed that the client–therapist relationship is at the core of treatment effectiveness. Yet by adhering to strict boundary regulations, many troublesome feelings are likely to arise and ruptures to emerge that destroy the necessary sense of trust and empathy. Greenspan (2002) aptly describes strict boundary adherence as a “distance model” that undermines the true healing potential of the work we do. I fully concur with her opinion that we need an approach of respectful compassion. Safe connection between therapist and client should be the overriding aim because this, not strict boundaries, will protect clients from abuse.

Conclusions
In this introductory chapter, we have examined what the codes of ethics of the major professional associations advise with respect to dual or multiple relationships. We have explored a number of factors that make such relationships problematic, as well as factors that create a potential for harm and the risks to parties directly or not directly involved in multiple relationships. Some strategies for reducing risks were described.
It is critical that counselors give careful thought to the potential complications before they become entangled in ethically questionable relationships. The importance of consultation in working through these issues cannot be overemphasized. As with any complex ethical issue, complete agreement may never be reached, nor is it necessarily desirable. However, as conscientious professionals, we need to strive to clarify our own stance and develop our own guidelines for practice within the limits of codes of ethics and current knowledge.

Chapter 4
Multicultural and Social Justice Perspectives on Boundaries

In this chapter, we address boundary considerations from multicultural and social justice perspectives. Sue and Sue (2013) describe social justice counseling as an active philosophy and approach aimed at producing conditions that allow for equal access and opportunity. “Social justice counseling with marginalized groups in our society is most enhanced (a) when mental health professionals can understand how individual and systemic worldviews shape clinical practice and (b) when they are equipped with organizational and system knowledge, expertise, and skills” (pp. 108–109). From this perspective, the helper’s role is broadened beyond that of a traditional mental health provider. Traditional models and techniques need to be aligned to best suit the diverse worldviews of clients. The strong individualistic bias of contemporary theories and the lack of emphasis on broader social contexts, such as families, groups, and communities, may not provide a wide range of clients with what they most need. In many cultures, collectivism is valued and identity is not viewed as being separate from the group orientation. Counselors with a multicultural and social justice orientation will be challenged to redefine the boundaries of their professional roles and to modify the way they practice with clients. Becoming a multiculturally competent counselor entails a shift in thinking and demands a different way of acting and practicing that several guest contributors describe in this chapter.

A few of the questions we explore in this chapter are:

· Is it ethical to barter with clients for goods or services?

· Under what circumstances, if ever, should a counselor accept a gift from a client?

· What are the appropriate limits of self-disclosure, and how could overextending these limits create a dual relationship problem?

· What alternative roles do counselors need to assume to effectively serve a culturally and ethnically diverse population?

· How does the social justice orientation differ from traditional approaches to counseling?

The choices practitioners make regarding these issues are likely to either confound or clarify their attempts to practice aspirational ethics within an increasingly diverse world.

A basic theme that runs throughout this chapter is that the cultural context needs to be considered when determining appropriate therapeutic boundaries with clients. Eight guest contributors add their voices to this chapter:

· Fred Bemak and Rita Chi-Ying Chung present multicultural and social justice perspectives on boundaries with culturally diverse clients.

· Derald Wing Sue and Christina Capodilupo explore the cultural context of working with boundaries and present an Asian perspective on reconsidering some counseling practices.

· Thomas A. Parham and Leon D. Caldwell provide an African-centered perspective in rethinking the definition of appropriate boundaries.

· Raul Machuca describes boundary concerns with Latino clients.

· Mevlida Turkes-Habibovic explores boundaries in counseling Muslim clients.

Bartering for Goods or Services

In the most recent revisions of the ethics codes of mental health professionals, the standards pertaining to bartering have been refined, and bartering is more generally discouraged. Although bartering is not often practiced and is not encouraged, the codes of various professions do recognize that there are circumstances in which bartering may be acceptable and that it is important to take into consideration cultural factors and community standards.

Counselors may barter only if the bartering does not result in exploitation or harm, if the client requests it, and if such arrangements are an accepted practice among professionals in the community. Counselors consider the cultural implications of bartering and discuss relevant concerns with clients and document such agreements in a clear written contract. (American Counseling Association [ACA], 2014, Standard A.10.e.)

Marriage and family therapists ordinarily refrain from accepting goods and services from clients in return for services rendered. Bartering for professional services may be conducted only if: (a) the supervisee or client requests it, (b) the relationship is not exploitative, (c) the professional relationship is not distorted, and (d) a clear written contract is established. (American Association for Marriage and Family Therapy [AAMFT], 2012, 7.5.)

Barter is the acceptance of goods, services, or other nonmonetary remuneration from clients/patients in return for psychological services. Psychologists may barter only if (1) it is not clinically contraindicated, and (2) the resulting arrangement is not exploitative. (American Psychological Association [APA], 2010, 6.05.)

Social workers should avoid accepting goods or services from clients as payment for professional services. Bartering arrangements, particularly involving services, create the potential for conflicts of interest, exploitation, and inappropriate boundaries in social workers’ relationships with clients. Social workers should explore and may participate in bartering only in very limited circumstances when it can be demonstrated that such arrangements are an accepted practice among professionals in the local community, considered to be essential for the provision of services, negotiated without coercion, and entered into at the client’s initiative and with the client’s informed consent. Social workers who accept goods or services from clients as payment for professional services assume the full burden of demonstrating that this arrangement will not be detrimental to the client or the professional relationship. (National Association of Social Workers [NASW], 2008, 1.13.b.)

Although the ethics codes do not prohibit bartering, they do offer cautions regarding the practice. There are potential problems with bartering, even though the practice may be motivated by an altruistic concern for the welfare of clients with limited financial resources. Kitchener and Harding (1990) pointed out that the services a client can offer are usually not as monetarily valuable as counseling. Thus, over time, clients could become trapped in a sort of indentured servitude as they fall further and further behind in the amount owed. Another potential problem concerns what criteria should be used to determine what goods or services are worth an hour of the therapist’s professional time.

The practice of bartering could open up more problems than it is worth. As an example, consider a client who pays for therapy by working on the counselor’s car. If the mechanical service is less than desirable, the chances are good that the counselor will begin to resent the client on several grounds: for having been taken advantage of, for being the recipient of inferior service, and for not being appreciated. The client, too, can begin to feel exploited and resentful if it takes many hours of work to pay for a 50-minute therapy session, or if the client believes the therapy is of poor quality. Feelings of resentment, whether they build up in the counselor or in the client, are bound to interfere with the therapeutic relationship.

Although bartering is not prohibited by ethics or law, most legal experts frown on the practice. Woody (1998), who is both a psychologist and an attorney, recommends against the use of bartering for psychological services because it could be argued that bartering is below the minimum standard of practice. If therapists enter into a bartering agreement with a client, Woody believes therapists have the burden of proof to demonstrate that the bartering arrangement (a) is in the best interests of the client; (b) is reasonable, equitable, and undertaken without undue influence; and (c) does not get in the way of providing quality psychological services to the client. Because bartering is so fraught with risks for both client and therapist, Woody believes prudence dictates that it should be the alternative of last resort. Even if bartering is monitored carefully to lessen the chance of exploitation, there is a high risk of allegations of misconduct.

Although we can see potential problems in bartering, we think it is a mistake to condemn this practice too quickly or in all cases. In some cultures or in some communities, bartering is a standard practice, and the problems just mentioned may not be as evident. For instance, rural environments may lend themselves more to barter arrangements. We know a practitioner who worked with farmers in rural Alabama who paid with a bushel of corn or apples. Within their cultural group, this was a normal way (and in some cases, the only possible way) of doing business. Many different kinds of barter arrangements could be agreed upon between counselor and client. There are also alternatives to bartering, such as using a sliding scale, doing pro bono work, or referring the client to another provider.

Before bartering is entered into, it is important that the client and the counselor talk about the arrangement, discuss problems that might develop along with alternatives that might be available, gain a clear understanding of the exchange, and come to an agreement in writing. Bartering is an example of a dual relationship that allows some room for practitioners, in collaboration with their clients, to use good judgment and consider the cultural context in the situation.

Barnett and Johnson (2008) and Koocher and Keith-Spiegel (2008) agree that bartering with clients can be both a reasonable and a humanitarian practice when people require psychological services but do not have insurance coverage and are in financial difficulty. They add that bartering arrangements can be a culturally sensitive and clinically indicated decision that may prove satisfactory to both parties. However, because of the risk involved in bartering practices, they recommend carefully assessing such arrangements prior to taking them on. This is an area in which counselors would do well to seek consultation from a colleague who can provide an objective assessment of the proposed bartering arrangements. Of course, all of these steps should be documented in the client’s clinical record.

Lawrence Thomas (2002), a clinical psychologist and a neuropsychologist, claimed that he never felt completely comfortable when he entered into a bartering arrangement, but each time he did so he believed bartering was the best alternative. Although bartering is a troublesome topic, it can be a legitimate means of helping out a person with financial difficulties. Thomas writes: “It can serve as a relatively dignified way for the patient to compensate the therapist for professional work” (p. 394). In his view, bartering should not be ruled out simply because of the slight chance that a client might initiate a lawsuit against the therapist. Thomas cautioned that venturing into any dual relationship requires careful thought and judgment and that the vast majority of professional work should be paid by the usual monetary means. When this is not possible due to a client’s economic situation, however, allowances should be made so that psychological services might be available. In short, bartering can be a way for the poor but needy client to obtain psychological services.

Thomas recommends a written contract, which should be reviewed regularly, that specifies the details of the agreement between therapist and client. Documenting the arrangement can clarify agreements and can also help professionals defend themselves if this becomes necessary.

· What is your own stance toward bartering?

· Do you see it as unacceptable in your own practice, or can you foresee instances when you might work out a barter arrangement that meets your professional code’s criteria for ethical practice?

· What cultural factors would you consider in deciding whether or not to barter?

· What standards within the community would you consider?

· What alternatives to bartering might you consider with your clients who are unable to pay your fee?

Accepting Gifts From Clients

The cultural implications of gift-giving are recognized in the ACA Code of Ethics (ACA, 2014):

Counselors understand the challenges of accepting gifts from clients and recognize that in some cultures, small gifts are a token of respect and gratitude. When determining whether to accept a gift from clients, counselors take into account the therapeutic relationship, the monetary value of the gift, the client’s motivation for giving the gift, and the counselor’s motivation for wanting to accept or decline the gift. (Standard A.10.f.)

The AAMFT (2012) also has a guideline regarding gifts: “Marriage and family therapists do not give to or receive from clients (a) gifts of substantial value or (b) gifts that impair the integrity or efficacy of the therapeutic relationship” (3.10.).

Neukrug and Milliken (2011), in their survey of ACA members, found that approximately 89% of counselors believed it was unethical to accept a gift worth more than $25 from a client. In an earlier study, Borys (1988) found that only 16% of respondents believed that it was never or only rarely ethical to accept a gift worth less than $10, but the percentage of those who disapproved rose to 82% when the gift was worth more than $50. Apparently, the monetary value of gifts is a major factor for counselors in determining whether it is ethical to accept them. Although expensive gifts certainly present an ethical problem, it is possible to be overly cautious and, in so doing, damage the therapeutic relationship. Rather than establishing a hard and fast rule, our preference is to evaluate each situation individually.

Other factors also need to be examined. Counselors need to be sensitive to cultural differences. As Derald Wing Sue, Christina Capodilupo, and Raul Machuca point out later in the chapter, gift-giving has different meanings in different cultures. The motivation of the client also needs to be considered. If the offering of a gift is an attempt to win the favor of the counselor or is some other form of manipulation, it is best not to accept the gift. It may be unwise to accept a gift without first having a discussion with the client. Gutheil and Brodsky (2008) maintain that the giving or receiving of gifts has layers of meaning, for both the client and therapy, that call for careful exploration. They suggest that in appropriate circumstances a gift may be helpful to therapy. Koocher and Keith-Spiegel (2008) contend that accepting certain kinds of gifts (highly personal items) is inappropriate and would require exploring the client’s motivation. Counselors may want to inquire about the meaning to the client of even small gifts. According to Zur (2011), any gift must be understood and evaluated within the context in which it is given. Zur believes that expensive gifts or any gifts that create indebtedness, whether of the client or the therapist, are boundary violations. However, Zur claims that appropriate gift-giving can be a healthy aspect of a therapist–client relationship and can enhance therapeutic effectiveness.

The relationship that has developed between the counselor and the client should be considered. Offering a gift may be the client’s way of expressing appreciation. For example, a client might bring a potted plant to a termination session as a way of saying “thank you” for the work that the counselor and client have accomplished together. If the therapist were to simply say “I cannot accept your gift,” the client might feel hurt and rejected. Gutheil and Brodsky (2008) take the position that when clients offer a small gift at the end of therapy it is customary to accept the gift if it is appropriate and of insubstantial value. However, acceptance of other gifts might be improper. For example, a client who is a corporate executive might offer her counselor a stock tip based on her insider’s knowledge. The counselor needs to explain to the client why it is improper to profit financially from information gained through a counseling relationship, and this could lead to a productive discussion about why the client felt a need to make such an offer. As is true of so many ethical dilemmas, one possibility is for the therapist to discuss his or her reactions with the client about accepting a gift.

One way to avoid being put in the awkward position of having to refuse a gift is to include a mention of the policy in your professional disclosure statement. The statement could include the information that, although counseling sessions may be intimate and personal, the relationship is a professional one and does not allow you to accept gifts. Although being clear with clients at the outset of the relationship does prevent some later problems, there will be instances when small gifts are offered and might be received in the spirit in which they were offered. Rather than using a price tag or some other arbitrary criterion to determine the ethics of accepting gifts, the counselor might choose to have a full and open discussion with the client about the matter.

· In your own practice, would you ever accept a gift from a client? Why or why not?

· What criteria would you use in deciding whether to accept or refuse the gift?

· Would you ever be inclined to give a client a gift? If not, why not? If so, under what circumstances would you give a gift to a client?

Limits of Self-Disclosure

Counselor self-disclosure has been an issue of ethical concern as a result of research such as that conducted by R. I. Simon (1991), who found that inappropriate self-disclosure is the type of boundary violation that is most likely to precede sexual intimacies. Nonetheless, Neukrug and Milliken (2011) found that nearly 87% of surveyed counselors rated self-disclosing to a client as “ethical.” Self-disclosure may be therapeutically beneficial or harmful, depending on a number of factors. The purpose of self-disclosure needs to be kept in mind. It is often relevant for a counselor to disclose his or her reactions to a client in the here-and-now of the therapy session, and this is more likely to have a therapeutic effect than disclosing details of one’s personal life to a client. As with other counseling interventions, self-disclosure must be a thought-out process. We must determine whether our self-disclosures are clinically sound therapeutic interventions or subtle boundary violations. When counselors disclose personal facts or experiences about their lives, the disclosures should be appropriate, timely, and done for the benefit of the client. Yalom (2003) acknowledged that the therapist’s practice of revealing aspects of his or her personal life can facilitate the therapeutic process, but he also suggests using caution.

If we find ourselves going into detail about our personal lives with our clients, we need to ask ourselves about our intentions and whose needs we are meeting. Clients are seeking our help for their problems, and they are not there to listen to our stories about our past or present struggles. Self-disclosure is a means to an end, not a goal in itself. If we lose sight of the appropriate professional boundaries with our clients, the focus of therapy might well shift from the therapist attending to the client to the client becoming concerned about taking care of the therapist.

A key ingredient in maintaining appropriate boundaries of self-disclosure is the mental health of the counselor. If we are not being listened to by our significant others, there is a danger that we might use our clients to satisfy our needs for attention. Our clients might become substitute parents, children, or friends, and this kind of reverse relationship is certainly not what our clients need. Instead, when we have conflicts or unresolved personal concerns, we need to address them with a colleague, a supervisor, or a therapist.

A Contributor’s Perspective

Fred Bemak and Rita Chi-Ying Chung present a multicultural and social justice approach to reconsidering boundaries in the therapeutic relationship. They develop the message that traditional models of counseling practice are grounded in assumptions that often are not effective when counseling people from diverse cultural backgrounds. They address a range of specific topics that call for adaptation to work from a multicultural and social justice framework. Some of the issues they address are community-based interventions, redefining self-disclosure, gift-giving, socializing with clients, the role of touch in counseling, bartering, and assuming alternate roles as helpers.

Cultural Boundaries, Cultural Norms: Multicultural and Social Justice Perspectives

Fred Bemak and Rita Chi-Ying Chung

Collectively we (Fred and Rita) have been working in cross-cultural and multicultural settings for five decades. A continual challenge in doing this work has been defining and maintaining boundaries with culturally diverse clients while providing counseling oriented toward social justice. A recurrent question we have both asked is how to broaden counselor–client relationships to incorporate culturally appropriate boundaries when working with clients who do not fit the traditional Western counseling paradigm. I (Fred) began my career working in an antipoverty program with ethnically diverse clients, and traditional boundaries accepted by the mainstream counseling profession were not applicable. I (Rita) am from a traditional Chinese background and was not born nor did I grow up in the United States. I have always challenged counseling and psychology definitions of boundaries and multiple relationships because they are incongruent with my Asian cultural worldview. If you are a mental health provider working in a multicultural setting, it is not surprising to me that you find dealing with boundaries and multiple relationships challenging.

Our role as helping professionals is to assist our clients in times of growth, change, and vulnerability. We believe that the power imbalance presents significant challenges for mental health professionals and has the potential to create ambiguity about one’s professional role and responsibility. This belief was supported in a national survey of psychologists that found the second most challenging concern in their day-to-day practice was “blurred, dual, or conflictual relationships” (Pope & Vetter, 1992, p. 399).

Given the importance of professional boundaries and relationships, the major professional mental health organizations—ACA, APA, AAMFT, and NASW—all have codes of ethics that address the topic of boundaries and multiple relationships with an intent to define the role of the therapist that will lead to the best therapy for clients. However, the boundary definitions in these codes of ethics are based on Western cultural values (Barnett, Lazarus, Vasquez, Moorehead-Slaughter, & Johnson, 2007). We are concerned that counselors working in cross-cultural or multicultural environments who adhere strictly to the Western counseling-based codes of ethics are in danger of losing their credibility. This may lead to client mistrust, premature dropout, and termination of therapy.

To compound the challenge of defining boundaries and relationships that were historically developed from a Euro-American framework is the dramatic racial and ethnic change in U.S. demographics, with rapidly growing numbers of people of color throughout the United States (U.S. Census Bureau, 2010). If we follow the changing racial and ethnic composition of the U.S. population, we can imagine the proportionate expansion of clients of color. Therefore, embedded in the increased cultural and ethnic diversity in the United States is a need to redefine counselors’ roles and responsibilities to become better aligned with the expectations and understanding about the therapeutic relationship with clients of color. Traditional Eurocentric, individualistic theories define boundaries in counseling in ways that limit culturally responsive therapeutic relationships for diverse clientele, who may have different expectations about counseling and healing. This disparity in the definition of boundaries and multiple relationships between the mental health professionals and clients can have a negative effect on the therapeutic relationship (Chung & Bemak, 2012).

Adding to the complexity of culturally responsive counseling is the necessity for mental health professionals to be attentive to social justice concerns with their clients (Chung & Bemak, 2012). A danger in applying boundaries that are rooted in legality rather than culturally responsive or social justice orientations is reconstructing historical oppression, racism, discrimination, and shame that are experienced by clients of color (Vasquez, 2005), which may retraumatize clients. To move beyond the limitations of the traditional boundaries rooted in psychodynamic theory, counselors must at times become advocates and partners with clients, helping to change the inequities in the client’s world, and facilitating culturally appropriate and justice-related healing within the context of the client’s community (Bemak & Chung, 2005; Chung & Bemak, 2012). Taking on this advocacy role might involve counselors working with elders; spiritual, religious, and community leaders; or indigenous healers.

These multiple roles necessitate flexibility when interpreting current ethical standards and require that we create new ways of defining boundaries and relationships that are responsive to cultural healing methodologies that have often existed for centuries. This leaves counselors trying to figure out their role and position with clients in relation to both culture and social justice. Counselors may experience anxiety and confusion in deciding which boundary crossings are acceptable and appropriate and how to cultivate a therapeutic relationship that is in the best interest of the client. Although the Multicultural Counseling Competencies (Sue, Arredondo, & McDavis, 1992; Sue et al., 1998) were established as guidelines for counselors to be culturally competent when working with clients from culturally diverse backgrounds, they do not address boundaries and multiple relationships across cultures or the ethical responsibility of a mental health professional in addressing social injustices.

In this section we would like to help you think critically about the importance of culture and social justice as important multidimensional and complex issues when considering crossing boundaries in counseling. Some boundaries are universal even when conducting multicultural and social justice counseling, such as counselors avoiding the misuse of their power by exploiting, disparaging, abusing, undermining, or harassing a client, or engaging in inappropriate behaviors and sexual relationships (Barnett et al., 2007). Lazarus (in Barnett et al., 2007) contends that all other aspects of ethics and boundaries are open for discussion. We agree that the Western psychological framework regarding boundary crossings must be reconsidered as it relates to clients from different cultural backgrounds and from oppressive life situations. It is especially important to rethink this framework given the rapidly changing ethnic and racial demographics in the United States and the numerous injustices that disenfranchised clients and communities encounter.

It is critical to examine seven issues as we adapt our practice and attend to multicultural and social justice boundary relationships:

1. Community-based interventions. Many communities of color are close-knit and foster a social level of engagement that is antithetical to Euro-American individualistically oriented cultures. The boundaries around relationships, confidentiality, and privacy established within communities of color are oftentimes much more loosely structured and based more on the African premise that “It takes a village to raise a child.” Numerous times when we (Fred and Rita) have provided counseling in racial and ethnically diverse communities both in the United States and overseas, we have found there is much broader community involvement in a community member’s problem and expectations that the neighbors and friends will become highly involved in providing both formal and informal psychological support. This collective involvement necessitates a very different construction of boundaries that is oftentimes at odds with traditional Western ethics codes regarding confidentiality and privacy.

2. Redefining self-disclosure. In ethnically and racially diverse communities there are expectations that the relationship becomes more than a formal, in-the-office, 50-minute session. Self-disclosure can contribute to the commonality shared with a client and can foster a greater sense of genuineness. In many cultures there is an expectation that counselors will share aspects of their personal lives, which in turn cultivates trust and openness. Self-disclosure is appropriate only when it is helpful for the client and serves to facilitate the therapeutic process, but it is important to remember that self-disclosure has the potential to be a powerful tool in building a connection with marginalized clients who have a history of oppression or culturally different clients who may be distrustful of the therapeutic process. For counselors not to self-disclose may create mistrust, loss of counselor credibility, client feelings of being unsafe, potential harm to the client, and premature termination. In Asian cultures self-disclosure may enhance rapport and enrich the counseling process (Kim et al., 2003). It is essential to keep in mind that crossing boundaries with clients from different cultural backgrounds requires knowledge, skills, competencies, and experience about the cultural, historical, and sociopolitical background of clients.

3. Gift-giving. In some cultures, exchanging gifts represents the spirit of helping, and giving back is a demonstration of one’s appreciation and gratitude. For a mental health professional to reject a reasonable gift, or at times to withhold giving a gift, can be perceived as insulting and as a rejection of the client’s culture. The expense and appropriateness of the gift must be considered, but it is important to keep in mind the cultural norms and the importance of showing respect and thankfulness by and to the client through the gift. Counselors must utilize their common sense with regard to gift-giving. One example of appropriate gift-giving happened when we were facilitating a parent and caretaker’s counseling group in an urban African American community. There was a plan to celebrate a group member’s 70th birthday in the group. Unfortunately, the member’s granddaughter was ill the evening of the group meeting, so the grandmother couldn’t attend. Both of us, along with other group members, drove to her home, which was located in a close-knit nearby community, brought a birthday cake, and sat on her front porch in the neighborhood celebrating the birthday. Many neighbors joined us in an animated discussion about problems, life, and healing. The trust established from this visit carried through with all the group members for the duration of the group. Another example relates to my (Rita) culture, in which it is customary for clients to bring food as a way of saying thanks. To reject the specially cooked food would be highly insulting.

4. Socializing with clients. In communities of color, everyone important in the client’s life, including the counselor, is invited to join major social events. We have been asked to weddings, graduations, funerals, baptisms, birthdays, special cultural holidays, and community celebrations. Clients may perceive the rejection of these invitations as a lack of concern or care and, more important, a lack of a meaningful relationship. When we were invited by a client from Somalia to his mother’s funeral, it was important for us to show our support for his grief and loss. To reject his invitation would have been an affront and would have caused great strain on the client–counselor relationship. One of our Brazilian colleagues, a well-established and sought-after psychiatrist, has made numerous house calls with clients, sharing meals, drinks, and social time with family members before engaging in home-based therapy. Not socializing with these clients, he explained, would have created serious obstacles in the therapeutic relationship.

5. Touch is important and human. How did boundary concerns move us away from human contact? In many parts of the world where we travel, communities are far more receptive to appropriate physical contact and touch. How did we become so phobic about appropriate touching, and why do we let litigation become a driving force in defining healthy, culturally responsive healing practices? Reaching out and making suitable physical contact with someone who is feeling alone and depressed, a child who is crying or in deep pain, or an individual sobbing after loss of loved ones in an earthquake is normal in many cultures. Both of us have held a crying child or an adult who was in deep pain after the loss of a loved one through terminal illness, suicide, a fatal accident, civil conflict, or a natural disaster. It is critical that we reassess the Western cultural norm regarding physical contact and begin to understand the meaning of touch for our diverse client populations. We are convinced that we must redefine appropriate boundaries regarding touch so that they are healing with racially and ethnically diverse clients. It is our experience that multicultural and social justice–oriented counseling must incorporate appropriate touch and physical contact.

6. Bartering. Many cultures are built on a bartering foundation. In addition, these clients may not have adequate resources to pay for counseling services. To effectively reach out and work with those without the financial means to pay standard counseling rates, address economic inequities, and provide multicultural social justice counseling from a culturally responsive framework, bartering is an excellent alternative to the traditional form of payment. Bartering must be thoughtfully worked out, keeping in mind the cultural context and the specific situation of each client. For example, when I (Rita) worked with immigrants who had limited financial resources, the clients and I would discuss and agree on an exchange other than money as a form of payment. These clients visited an elderly person, helped out a person with disabilities, or tutored a newly arrived immigrant in return for counseling services. In other instances, both of us have worked out arrangements that were specific to clients, such as an exchange of home-baked goods by clients who were proud of their cooking skills, goods that were in turn shared with others and oftentimes donated to places such as homeless shelters, in return for counseling services.

7. Different roles create different boundaries. Attending to social justice issues and providing culturally responsive counseling requires us to take on different roles. At times we are advocates for our clients, at other times we are advisers, and sometimes we help generate social change in times of injustice or inequity. Still other times, mental health professionals find themselves being the liaison with culturally responsive healers such as elders and spiritual or religious healers. Each of these roles requires an expansion of traditional counseling responsibilities and functions from those based on the boundary definitions included in ethics codes. For example, we may become advocates to assist clients in gaining skills that would challenge discriminatory practices in their worksite, we may call on the Imam of the Mosque (mosque prayer leader) to speak with a client who is struggling with spiritual issues related to Islam, or we may become an adviser and provide directive interventions to a client coming from a culture where expectations are to receive explicit instructions from someone in an esteemed position like a counselor. Each of these singular roles requires a reconstitution of boundaries.

Final Thoughts

There is an inherent long-standing tension regarding boundaries and boundary crossings between the traditional psychodynamic model and the social justice approach of responding to racially and ethnically diverse clientele and oppressed populations. This tension mirrors much deeper divisions within the mental health field. It is imperative that we reexamine fundamental aspects of the counseling relationship that have a significant bearing on culture and social justice as a way to help us rethink the meaning, context, and practice of legality and humane practice that have bearing on social injustices and culture. As counselors we need to ask ourselves, “Whose boundaries are these?” “Do the boundaries help or hinder clients’ growth, development, and psychological well-being?” “If not, can we redefine the boundaries to more effectively respond to multicultural social justice issues facing clients?”

Alternative Counselor Roles in Working With Diverse Clients

Counselors today, regardless of the setting in which they work, are likely to encounter challenges in meeting the needs of diverse client populations. Working effectively with culturally and ethnically diverse clients may entail a willingness to assume nontraditional roles and to adopt various roles at different stages in the helping process. Some of this role shifting may look like multiple relating and crossing boundaries that are traditionally marked; however, combining roles may be necessary to counsel effectively in a multicultural community.

Counselors who work with ethnically diverse clients may need to shift their thinking because sticking with a singular role may limit their ability to reach these clients. According to Atkinson, Thompson, and Grant (1993), practitioners are generally best trained to play the role of psychotherapist, but this is the role most frequently misapplied in working with racial or ethnic minority clients. Atkinson and his colleagues believe that the conventional role of psychotherapist is appropriate only for clients who are highly acculturated and want relief from an existing problem that has an internal etiology.

Sue and Sue (2013) have criticized conventional approaches to therapy that focus on a client’s intrapsychic conflicts and tend to place undue responsibility on clients for their plight. At the extreme, some interventions can be perceived as blaming client problems on the client rather than as examining real factors in the environment that may be contributing to the client’s problem. Many of the writers with a community orientation have emphasized the necessity for recognizing and dealing with environmental conditions that often create problems for diverse client groups rather than merely working to change an individual client’s behavior.

In selecting roles and strategies to use with diverse clients, Atkinson et al. (1993) believe it is useful to take into account the client’s level of acculturation, the locus of problem etiology, and the goal of counseling. These writers and Atkinson (2004) have suggested that several alternative roles—advocate, change agent, consultant, adviser, and facilitator of indigenous support systems—are appropriate for counselors who work in the community. These alternative counselor roles embody fundamental principles of social justice and activism that are aimed at client empowerment. Rita Chi-Ying Chung and Fred Bemak stated that at times they are advocates for their clients, at other times they are advisers, and sometimes they focus their efforts on social change to combat injustice or inequity. Each of these roles requires an expansion of traditional counseling responsibilities and functions.

Later in this chapter Derald Wing Sue and Christina Capodilupo describe the necessity for counselors to become competent carrying out nontraditional roles and reaching diverse members of a community. One of these roles is assuming the role of advocate when cultural groups are oppressed by the dominant society. Counselors can speak on behalf of clients who are low in acculturation and need help with problems that result from discrimination and oppression. Chung and Bemak (2012) contend that by adhering to traditional roles, mental health practitioners are maintaining and reinforcing the status quo, which results in politically supporting the social injustices, inequalities, and discriminatory treatment of certain groups of people. Chung and Bemak view becoming an advocate for empowerment as a central core of counseling that involves time and making a commitment to this goal. They take the position that advocacy is an ethical and moral obligation for becoming an effective counselor. The ACA Code of Ethics (ACA, 2014) acknowledges the importance of advocacy for clients whose problems result from discrimination and oppression (Standard A.7.), and the Code includes the promotion of social justice as a core value of the profession.

In the role of change agent, counselors can make use of political power to confront and bring about change within the system that creates or contributes to problems that clients face. In this role, counselors assist clients to recognize oppressive forces in the community as a source of their problems and teach clients strategies for dealing with these environmental problems. A change agent recognizes that healthy communities produce healthy people. In their role as change agent, counselors must at times educate organizations to change their culture to meet the needs of the community.

By operating as consultants, counselors often assume the role of teacher. They can encourage clients from various ethnic groups to learn skills they can use to interact successfully with various forces within their community. The client and the counselor work together collegially to address unhealthy forces within the system and to design prevention programs to reduce the negative impact of racism and oppression.

The counselor as adviser discusses with clients ways to deal with environmental problems that are contributing to their personal problems. This is much like a social work approach that considers the person-in-the-environment rather than addressing problems as residing solely within the individual. For example, recent immigrants may need advice on coping with problems they will face in the job market or that their children may encounter at school.

For many ethnically and culturally diverse clients, seeking help in the form of traditional counseling is foreign. Often they are more willing to turn to social support systems within their own community. By acting as facilitators of indigenous support systems, counselors can encourage clients to make full use of the resources in their communities, including community centers, extended families, neighborhood social networks, churches, and ethnic advocacy groups. Counselors need to learn what kinds of healing resources exist within a client’s culture. In many cultures, professional counselors have little hope of reaching individuals with problems because these individuals are likely to put their trust in folk healers, acupuncturists, and spiritual healers who are a part of their culture. At times, it may be difficult for counselors to adopt the worldview of their clients, and in such instances it could be helpful to make a referral to an indigenous healer. Counselors can then structure their activities to complement or augment the healing resources available for the client.

For counselors who hope to reach a diverse range of client populations, it is essential to be able to employ therapeutic strategies in flexible ways and to assume various roles in helping clients. Combining roles will be necessary to help many clients effectively. Counselors who assume a social justice orientation are not merely concerned with bringing about changes within the individual; rather, they are interested in instigating social change. Competent multicultural and social justice counseling calls for practitioners who are familiar with community resources, know the cultural background of their clients, have skills that can be used as needed by clients, and have the ability to balance various roles. For thoughtful discussions of case examples of social justice programs and re-envisioning the practice of counseling, we recommend Helping Beyond the 50-Minute Hour: Therapists Involved in Meaningful Social Action (Kottler, Englar-Carlson, & Carlson, 2013). For comprehensive discussions of social justice and systems changes as applied to working with diverse client populations, see Social Justice Counseling: The Next Steps Beyond Multiculturalism (Chung & Bemak, 2012).

A Contributor’s Perspective

Derald Wing Sue and Christina Capodilupo expand on some alternative roles in helping that may be implemented in various communities. They eloquently present an ethical framework for viewing dual or multiple relationships from a multicultural perspective. Their contribution shows how boundaries take on special meaning when working in the community.

Multicultural and Community Perspectives on Multiple Relationships

Derald Wing Sue and Christina Capodilupo

Mental health professionals are increasingly being confronted with situations that challenge the standards of practice and codes of ethics developed by their professional associations (Sue & Sue, 2013). Such is the case with dual or multiple relationships. Once counselors have entered into a therapeutic relationship with a client, the role they play becomes relatively prescribed. Traditionally, that role has been defined as working for the “therapeutic good” of clients, avoiding undue influence, allowing clients to make decisions on their own, setting clear boundaries, and maintaining objectivity by preventing personal bias from entering counseling decisions. It is believed that such a therapeutic relationship is sacrosanct, and indeed ethics codes have arisen around it to protect clients from being “taken advantage of” or “harmed.”

Codes of ethics have clear guidelines that warn against multiple relationships because such relationships potentially compromise the therapeutic role. There is good reason for the existence of these standards, and some psychologists assert that relationship boundaries should remain rigid and well defined. Others have begun to raise questions and issues regarding the universal application of such standards to all situations, problems, and populations, suggesting that multiple relationships are not necessarily problematic, especially in the context of small communities (Schank & Skovholt, 2006; Sue, Ivey, & Pedersen, 1996). First, concepts of mental health, the therapeutic process, and the roles helping professionals play are grounded in modern Euro-American culture. Some cultural groups may value multiple relationships with the helping professional. Second, some dual or multiple relationships may be unavoidable. This is especially true in smaller towns and rural areas where there are very few mental health professionals (Campbell & Gordon, 2003; Schank & Skovholt, 2006). Finally, some mental health professionals believe that multiple relationships based on nontraditional helping roles may be more beneficial than harmful. For example, it has been suggested that multiple relationships may facilitate the use of mental health services among those in rural areas (Schank & Skovholt, 2006); communities of color (Pedersen, 1997); religious communities (Case, McMinn, & Meek, 1997); and the lesbian, gay, bisexual, and transgender (LGBT) communities (Graham & Liddle, 2009).

The multicultural counseling and therapy movement has sensitized many to the fact that standards of normality and abnormality, the counseling role, and what is considered therapy are culture bound (Parham, 2002; Santiago-Rivera, Arredondo, & Gallardo-Cooper, 2002; Sue & Sue, 2013). In Asian culture, for example, it is believed that intimate matters (self-disclosure) are most appropriately discussed with an intimate acquaintance (relative or friend). Self-disclosing to a stranger (counselor) is considered taboo and is a violation of familial and cultural values. Thus certain Asian cultures may encourage a “dual” or “multiple” relationship in which the helper is also a relative or close personal friend. An Asian client’s desire to have the traditional counseling role evolve into a more personal one is often perceived by a Euro-American–trained counselor as inappropriate and manipulative. In addition, gift-giving is a common practice in many Asian communities to show gratitude, respect, and the sealing of a relationship (Sue & Sue, 2013). Such actions are culturally appropriate, yet counselors unfamiliar with such practices may feel that it is inappropriate to accept a gift because it blurs boundaries, changes the relationship, and creates a conflict of interest. They may politely refuse the gift, not realizing the great insult and cultural meaning of their refusal for the giver. In direct recognition of this cultural consideration, the ACA Code of Ethics (ACA, 2014) specifies that “counselors . . . recognize that in some cultures, small gifts are a token of respect and gratitude” (Standard A.10.f.).

The multicultural counseling movement has also challenged the traditional roles played by counselors who work in the community. Most counselors are taught that therapy is conducted in an office environment, is directed toward remediation, and is a one-to-one process. They are taught that the counselor is relatively inactive and that clients must make the decisions and take responsibility for their own actions. Yet in many cultural groups, including among African Americans, Hispanic/Latino(a) Americans, and Asian Americans, clients prefer to receive advice and suggestions because they perceive the counselor to be an expert with higher status who possesses special knowledge and expertise. The roles they find helpful may not be the traditional counseling role but other, more active roles. Atkinson et al. (1993) and Atkinson (2004) have identified different helping roles that the professional needs to develop to become multiculturally competent and to work effectively in the community. These roles are associated with client needs and characteristics: internal versus external locus of the problem, level of acculturation/knowledge of the home culture, and whether the overall goal is one of remediation or prevention. Playing more than one of these roles implies the establishment of a dual or multiple relationship. Similarly, LGBT therapists often find themselves in overlapping relationships with LGBT clients who share their communities. It has been suggested that LGBT therapists need to maintain flexibility and constantly negotiate personal and professional boundaries in an effort to effectively manage these multiple relationships (L. E. Kessler & Waehler, 2005).

In smaller communities and in our historical past, it was not unusual for citizens to play multiple roles such as storekeeper, neighbor, teacher, and friend. With increasing urbanization, such cross-mixing of relationships has become rare in the cities. As Forester-Miller and Moody discuss later in this book (

Chapter 11

), a counselor or therapist in a smaller community may find it exceedingly difficult not to have other relationships with her or his clients. Similar assertions have been made for LGBT therapists (Graham & Liddle, 2009).

Our codes of ethics now recognize that multiple relationships may be unavoidable, that not all such relationships are harmful, and that under certain conditions they may even be therapeutically beneficial. A helpful distinction was made between boundary crossing and boundary violation by Zur and Lazarus (2002). A boundary crossing is a harmless and often helpful deviation from traditional clinical practice, whereas a boundary violation is a departure from accepted practice that is harmful and exploitive. These scholars argue that boundary crossings are likely to “increase familiarity, understanding, and connection and hence increase the likelihood of success for the clinical work” (p. 6). In general, the guidelines discouraging dual relationships are well intentioned and basically sound. However, they must not be rigidly applied to all situations. As we have seen, community characteristics (rural versus urban, small versus large, LGBT, and community acceptance of certain practices such as bartering), multicultural redefinitions of counseling roles, and cultural perceptions of helping practices must be considered. Given the fact that counselors may unavoidably find themselves in a dual relationship or faced with a potential one, what guidelines can be used to minimize harm? Here are a few suggestions to consider:

· Personal and professional integrity must be the guiding force behind a decision to enter a dual relationship or to maintain one. Counselors must consider the good of the client first and not allow personal or professional agendas to interfere with the therapeutic relationship. The decision must be based not solely on “good intentions” but on whether the relationship actually impairs or harms the therapeutic goals or whether the risks for harm are too great. Mental health professionals should assess whether they are using the power differential to exploit their client in any way.

· Counselors must be thoroughly knowledgeable about their profession’s code of ethics and the spirit in which it was developed. Written statements cannot cover all situations. Many, like the examples given earlier, are not covered by clear guidelines, and to stick to “the letter of the law” may harm clients. Adhering to a dichotomous definition of the therapeutic relationship may obscure subtleties in cultural expectations and prevent effective treatment (Glass, 2003).

· Counselors must educate themselves about cultural and community standards of practice. For example, if a counselor decides to accept a gift from a client or to accept barter as a means of exchange, the actions must be judged according to the client’s cultural context and by the community’s normative standards.

· If a counselor does not feel comfortable with a dual relationship or if it contains too many potential risks, it is the responsibility of the counselor not only to make this clear to the client but also to offer alternative means by which services can be obtained (other community resources or helpers).

· It is unrealistic to expect any single helping professional to rely solely on self-monitoring as a means for avoiding problematic dual relationships. In all situations when a counselor considers entering into or is unavoidably involved in a dual relationship, it is recommended that consultation with colleagues be sought. Indeed, continual consultation and monitoring of the situation must be the cornerstone of any continuing dual relationship.

A Contributor’s Perspective

Derald Wing Sue and Christina Capodilupo make it clear that as counselors working in the community, we need to rethink and revise our traditional definitions of therapeutic boundaries if we are to reach and serve a multicultural clientele. Thomas Parham and Leon Caldwell agree that boundaries need to be reconsidered by multiculturally competent counselors, and they discuss multiple relationship issues from an African-centered worldview.

Boundaries in the Context of a Collective Community: An African-Centered Perspective

Thomas A. Parham and Leon D. Caldwell

We explain the African-centered worldview in more depth here to provide guidance to students, practitioners, and supervisors who are challenged to express this worldview against a backdrop of Eurocentric standards regarding relationships. We intend to offer a reprieve to those who themselves are or who provide counseling to culturally conscious African Americans.

In an earlier edition of this book, Parham (1997) contended that framers of ethical standards have anchored their objections to dual relationships in several primary themes. First, dual relationships are discouraged because they potentially compromise the clinician’s objectivity and professional judgment. Apparently, it is believed that secondary and tertiary relationships increase the probability that professionals will develop strong emotional ties that potentially compromise their ability to make objective decisions. Second, dual relationships are discouraged to prevent the helpee (either client or student) from projecting inappropriate dependency needs onto the helper. A third rationale centers around the power differential between helper and helpee and the degree to which those dynamics contribute to or invite helpee exploitation by the professional. The latest revision of the APA (2010) ethics code has lessened the imperative to “avoid at all costs” any dual or multiple relationships and now reflects a more culturally sensitive caveat that dual and multiple relationships must be appropriately managed to avoid exploitation. However, many codes of conduct continue to place blanket prohibitions against dual and multiple relationships. The inherent epistemological and axiological assumptions of these codes should be examined because they may, in fact, prove to be an obstacle or hindrance when working with African American clients.

Helms and Cook (1999) extended this notion that ethical standards represent barriers for some ethnic communities by observing that the standards themselves have been influenced by traditional theoretical perspectives. They imply that cultural conflicts potentially emerge when strict adherence to Eurocentric ethics codes bumps up against other cultural mores, values, and traditions that have different foundational values. They further caution that cultural conflicts that result from rigid ethical and professional guidelines can lead to negative therapeutic consequences such as cultural conflict, client confusion, and early termination.

To understand the foundation of relationships in an African-centered context, one must first understand the role of a healer, why relationships have power, and why boundaries are permeable rather than rigid. Within the context of an African-centered therapeutic space, counseling professionals are considered to be healers. Healers participate “with their clients” rather than “on their clients” in helping them to confront their intellectual, emotional, behavioral, and spiritual debilitations (Hilliard, 1998; Parham, 2002). Healers recognize that the resolution of personal challenges occurs through many forms and across many contexts. Therefore, to limit their space is to diminish their opportunity to practice their healing art. Fu-Kiau (1991) articulated this idea by reminding us that therapy in an African context is not confined to a mental health professional’s office, nor is it conducted in strict 50-minute hours. Therapy involves multiple activities and can include conversation, but also play, shared meals and cooking, travel, rituals and ceremony, singing or drumming, storytelling, writing, touching, and laughter.

For example, therapy can be conducted while the client and therapist are taking a casual stroll through a neighborhood park or outdoor area near the office. Assignments and suggestions can also be given in which the client may be invited to engage in a playful activity, cooking experience, or journaling exercise. Each of these activities, when performed by the client, has the potential to bring a “healing focus” to the experience. Although the therapist may engage in some of these activities with the client, it is likely that the client will adopt some of these activities and perform them in the absence of the therapist. In this way, the client begins to understand the healing process.

1. Being “open” to healing experiences is a first step in enhancing a client’s self-healing power.

2. Healing can occur anywhere and at any time, including spontaneous experiences with unplanned events, or even people one meets by chance.

3. People and events become “healing” not simply because they exist or occur but because they instigate a thought, feeling, or spiritual insight that helps the client to appreciate some aspect of the self that he or she might have been struggling to understand.

Consequently, a healing aspect of therapy in a traditional office setting might include giving the client a hug to end the session. It may include performing a ritual with the client (e.g., sharing a libation) at the beginning of the session or processing the particular aspects of a recreational activity the client engages in while the therapist is in attendance and observing the client.

Fundamentally, Africans and people of African descent live in a collective world and see every action in terms of a collective community. Unlike the Eurocentric focus on individuals as independently functioning entities, people of African descent belong to a group and derive their power from the collective energy of the group, tribe, or family. Healers must recognize this and utilize the community in all of its aspects as potential healing places and spaces.

The nature of relationships for African American practitioners and clients is inherently dualistic. Professional standards of conduct, training environments, and practices that disregard alternative cultural perspectives on relationships place culturally conscious African American students and practitioners at risk for ethnic community alienation or professional misconduct.

In understanding the role of a healer, it is also important to understand why relationships have power. People in many African cultures believe that each person is endowed with a spirit or life force that is divinely inspired. That energy is often referred to as an individual’s “self-healing power” (Fu-Kiau, 1991). An individual’s power can be diminished by being out of balance with his or her rhythm and natural order or by becoming too distant from the energy of the collective community. Thus therapeutic practice, irrespective of theoretical orientation, is not simply viewed as an art of healing but as a practice of regenerating an individual’s self-healing power. That regeneration occurs through the interaction of therapist and patient, whose relationship creates a synergy that is transformative. Thus therapeutic practice in an African-centered context has less to do with boundary issues or dual relationships and more to do with what is transformative or healing within a specific therapeutic context.

In remembering that imperative, one can now see why African-centered ethics codes begin and develop in a concern for the quality of human relations. A fundamental African principle states that human beings realize themselves only in moral relations to others. Unlike Eurocentric ethical standards, which appear to be designed to control people’s behavior, African-centered ethics invite people to aspire to “right ways of being.” The African worldview fundamentally believes in the ontological principle of consubstantiation; that is, elements of the universe are of the same substance. There is an interconnectedness between the helper and the helpee, and developing and maintaining emotional and spiritual connections is considered facilitative.

In recognizing that professionals and students alike may have difficulty navigating their way through different culturally congruent and incongruent sets of ethics codes of conduct and professional standards of practice, perhaps there is a need for some suggested methods of approach. We offer the following helpful hints to the African American students and professionals, their supervisors (irrespective of cultural background), training programs, and service delivery agencies and organizations who are invested in applying more culturally sensitive ethics to their practice.

Helpful Hints for African American Trainees

· Be aware of all the professional standards and guidelines that exist within the entire professions of psychology and counseling.

· Be aware of the ethical standards that are adopted in the agency in which you work or train.

· Be cognizant of your position and cultural expertise in the community.

· Be aware of the client’s worldview and how it might influence your application of particular ethical principles.

Helpful Hints for Supervisors of African American Trainees

· Develop awareness of your own cultural competence, including your limitations.

· Develop awareness of cultural expectations held by African American and other culturally different trainees and how those might vary by level of racial identity development.

· Acknowledge that when dealing with African Americans supervisees may be more culturally aware and confident about certain aspects of their work than the supervisor.

Helpful Considerations for Professional Therapists

· Examine your own interpretation of the ethical guidelines and how those inform your practice.

· Engage in some deep thinking about how ethical guidelines may affect your work with particular clients.

· Make appropriate use of the consultation process with colleagues who are more culturally competent and those who can render judgments that broaden the options to consider.

· Support policies that recognize that dual relationships are inherent and culturally expected.

Considerations for Training Programs

· Acknowledge multiple perspectives on relationships.

· Train students in ways that highlight relationship management rather than relationship avoidance.

· Teach awareness of exploitation and harm by encouraging peer consultation.

· Help trainees examine what drives the decision-making codes (mandatory ethics versus social constructivism).

· Acknowledge when individual cultural competence may conflict with organizational or institutional competency guidelines. Practitioners can advocate for policy change, education, and general awareness of institutional conflict when this occurs.

· Teach trainees to share with the community what our professional ethical obligations are and how they affect our strengths and limitations.

· Develop a clear, articulated decision-making strategy prior to facing an ethical problem.

Considerations for Agencies and Organizations

· Conduct a cultural audit to examine ways in which the organization’s policies and practices might affect the client base served by that agency.

· Examine agency protocol and how power and decision making are used to address cultural competence through ethical practice.

· Recognize that there are multiple perspectives on interpreting ethics codes and professional standards regarding boundaries.

· Conduct retreats and periodic meetings to review ethical standards and dilemmas challenged by developing levels of cultural competence within the agency.

Summary

It is important to consider boundaries and dual relationship standards when we provide services to clients or students in our professional roles. However, it is also important to take into account cultural traditions and value systems that differ markedly from those underlying the standards embraced by professional associations as we develop appropriate roles and responsibilities for a profession that is becoming increasingly multicultural. Conducting one’s affairs in ways that adhere to established professional codes of conduct can be a challenge. This is particularly true when those standards are congruent with only one cultural perspective to the exclusion of others, and the clients are culturally different as well. Boundary issues are only one element in a list of ethical standards that needs to be examined for cultural sensitivity. In doing so, we enhance our own level of cultural competence and help to ensure that those whom we counsel and teach are treated in ways that best address their needs, and not just our own.

A Contributor’s Perspective

Our next contributor, Raul Machuca, draws on his own experience as a Latino immigrant and as a counseling student and counselor in the United States to address boundary issues from a Latino perspective.

Boundary Issues in Counseling Latino Clients

Raul Machuca

Perceptions of boundaries and boundary crossings are intimately related to the cultural backgrounds of both the client and the counselor. In this contribution, I refer to my personal experience as a Latino clinician to illustrate ways in which certain boundary issues may arise in working with Latino clients as well as ethical and therapeutic ways of addressing them. As a Latino immigrant, my perception of boundaries has evolved as a consequence of my own acculturation process in the United States and as a result of continuous negotiation between my cultural values and the values of a Eurocentric counselor education process.

Different cultural groups may not necessarily understand the concept of boundaries in the same way as those who have a Western Eurocentric mentality. For Latino clients, particularly those with a lower level of acculturation, it is quite difficult to comprehend the mere existence of a rigid professional boundary between them and a counselor to whom they have revealed their most intimate secrets. For Latino clients, it is not necessarily clear that a therapeutic relationship is different from a personal relationship. The distinctions may not be clear to Latino counselors, either. In my case, I realize that I am going through an acculturation process parallel to that of my clients.

Although difficult to achieve, a clear understanding of how boundaries and boundary crossings play a role in working with Latino clients is a basic tool in facilitating more culturally sensitive and effective work within this population. The negotiation of boundaries to facilitate a more effective therapeutic relationship with Latino clients is a sign of cultural competence. With Latino clients, clinicians need to be attuned to Latinos’ appreciation for a greater degree of personal warmth, the desire to relate to the counselor at a more personal level, a greater level of comfort with affection and touching, and closer personal space, all while maintaining the professional hierarchical relationship that is expected in the U.S. culture.

My understanding of how boundaries function in the therapeutic relationship has been a process that started during my days as a Latino graduate student from Colombia. As an international student, I was mainstreamed into what seemed to me to be a rigid Eurocentric way of becoming a professional counselor. I remember, for instance, finding it difficult to grasp the idea that we could listen and have an empathic conversation with someone and remain within the constraints of ethical, legal, and cultural rules. One of the first things that I noticed was the significant difference between myself and some of my American classmates in terms of understanding and establishing clear and definitive boundaries with clients from the outset of the therapeutic relationship. It just did not feel quite right for me to make it clear to a client from the beginning that everything we talked about was confidential, but that confidentiality was not absolute because there were specific instances in which I was mandated to report. In my primitive counseling mind at that time, I imagined myself going to a counselor who would tell me that and thinking that I could not entirely trust him. I also struggled with messages that, again in my primitive counseling mind, sounded like absolute commands: no touching, no self-disclosure, no accepting of gifts. As a Latino, the idea that I could not shake my client’s hand, talk about myself, or even accept gifts felt somewhat cold, distant, and even disrespectful. At that time, I remember that my strategy to deal with this “cultural dissonance” was (apart from meeting unavoidable legal requirements) to simply relate to my Latino clients using a greater degree of personal warmth than with my non-Latino clients.

Working with Latino clients presents many opportunities for boundary crossings that can help establish a more effective therapeutic relationship. Some of the most common boundary crossings I have encountered as a Latino clinician working with Latino clients are related to the perception of and adherence to time limits, self-disclosure, gift-giving, participation in family and social events, and community interactions.

A general stereotype about Latinos is that they have a different perception of the importance of time, particularly in terms of punctuality and time management. There is what we call “Colombian time,” although it applies to other Latino groups, which basically means that it is somewhat socially acceptable and expected to be fashionably late. Although this wasn’t present among all my Latino clients, I remember having to plan my schedule to account for these late arrivals, especially for the first sessions. Another time-related boundary that needed to be stretched, for both my clients and for me, was having a predetermined amount of time for sessions. As a beginning clinician, I struggled with the mere idea of having a session that could not go beyond 50 minutes. Time limits were also regularly ignored by my Latino clients, many of whom expected our interactions to go on as long as they felt it was necessary. I remember having very long sessions and struggling to end many of them. Later, I learned to structure my sessions by incorporating a more realistic agenda to make it clear that the sessions would come to an end once specific goals were met.

Another issue that I often encounter as a Latino counselor is self-disclosure. In my early process of acculturation, I found it difficult to balance being completely genuine with what I perceived as rigid commands of the counseling profession: “avoid self-disclosure, “do not respond to personal questions,” and “state specific limits about interactions.” As I gained more experience, I realized that establishing rapport was easier with my Latino clients if I was prepared to respond to personal questions rather than avoiding them, exploring their intentionality, or stressing the client-focused nature of our interactions. I was typically asked about my country of origin, time in the United States, marital status, and even family composition. I also realized that sometimes my clients would not ask but would make assumptions about me. My way of dealing with this was to maintain the assumption without actively deceiving the client: Unless I was asked directly, I would not volunteer information even when I perceived that the client may have assumed something about me that could have been inaccurate. Many of the assumptions were positive and facilitated a greater level of identification and opportunity to relate. The most typical assumptions were related to perceived common experiences for Latin Americans such as the immigration process, socioeconomic status, cultural values, and religious beliefs.

As a Latino, I knew that refusing a gift could be considered a grave offense for my Latino clients. I also knew that as part of the dynamics of our professional relationship I had to expect clients to feel a need to reciprocate the help gained from counseling. Often, there was from the beginning an understanding that I would be offered something, particularly food, as a symbolic appreciation for my services. I struggled with negotiating what would be acceptable to receive and how to politely refuse any excess of generosity. In many cases, the negotiations came down to a glass or bottle of water, with the occasional surprise of a special traditional dish.

In Latino culture, once you get to know the family secrets you become part of the family. Therefore, invitations to all sorts of family events were a constant in my practice. I found that openly refusing an invitation did not work to help establish and maintain a strong therapeutic relationship. I came to realize that just considering the possibility of attending was sometimes enough to convey my appreciation of a client’s gesture, even if I could not or simply decided that I would not attend.

Finally, to facilitate the specific needs of Latino clients and ensure a successful counseling experience, it helps to provide opportunities for Latino clients to relate to you as a person, although this entails boundary crossings that may not be required when working with other populations. In my case, the fact that I am a Latino counselor working with Latino clients makes it quite common that our social lives sometimes overlap. A common situation in which boundaries are tested at the social level has to do with being open to unsolicited advice given by clients on all sorts of issues such as health, cultural events, and in my case, Latino-related shopping and groceries. I remember a client who asked me if I had visited a store she recommended as soon as she knew I was Colombian. She wanted me to try what she considered the best Colombian empanadas in town. When I did and told her that I had done so, I realized how significant it was for her to feel that she could reciprocate the support she felt she was receiving from me.

In conclusion, addressing boundary issues with Latino clients requires clinicians to become familiar with the cultural values of this population and make a special effort to accommodate the clients’ values into the somewhat more rigid Eurocentric approach to counseling. As an immigrant Latino counselor, walking the acculturation path alongside my clients has helped me to appreciate the importance of being flexible.

A Contributor’s Perspective

Our next contributor, Mevlida Turkes-Habibovic, draws on her own experience to address boundary issues from a Muslim perspective. She suggests the importance of distinguishing between Muslim clients’ religious and cultural beliefs.

Boundary Considerations in Counseling Muslim Clients

Mevlida Turkes-Habibovic

As has been noted, contemporary literature suggests that boundary crossings sometimes can be appropriate and have therapeutic value. For practicing Muslims in the United States, some counselor behaviors that might be considered boundary crossings in the Euro-American counseling worldview are seen as a natural part of a helping relationship.

Although the ethics codes of the mental health professions acknowledge diversity and cultural sensitivity, religion and its influence on clients’ lives seems to be overlooked. Religion and culture are used as interchangeable terms, and the lines between them are often blurred. However, the distinction is important when counseling practicing Muslims. It is critical to understand both the religious and the cultural beliefs of practicing Muslims. Often, religious identity overshadows cultural identity. For example, an African American Muslim and a European immigrant Muslim may have very different cultural backgrounds yet may be much alike with respect to the overarching importance of religion in their lives.

I believe that integration of religion into therapeutic conversations improves counseling services to clients for whom Islam is an integral part of their lives. Lack of trust in service providers with other religious backgrounds is not uncommon among Muslims. If Muslims could rely on the integration of their religious beliefs into the counseling process, the underutilization of services among this population might be significantly reduced.

Religious coping, founded on Qur’anic and Prophet Muhammed’s (pbuh) teaching, is an important aspect of Muslim life. Religious coping may involve reading the Qur’an in both Arabic and the client’s native language, reading hadiths (Prophet’s [pbuh] sayings), making supplications, giving to charity, performing voluntary prayers, gathering the Islamic perspective about the issue in question, seeking help from an Imam, and utilizing indigenous treatment methods. Religious coping is relevant to counseling, has therapeutic value, and could be considered a form of bibliotherapy that could be appropriately incorporated into therapy. Counselors could use the client as a source of this knowledge, and they could greatly benefit from consultative relationships with Muslim religious leaders and local Imams. Although many differences exist among Muslims in the United States, Islam is the factor that unifies their daily activities and experiences. It is important for counselors to discuss with the client the role that Islam has in his or her life. Rather than waiting for the client to self-disclose this information, it is beneficial for the counselor to explore it in the initial session; this would not only influence rapport but also increase trust, especially if the counselor has a different religious background. Being open to exploration of a Muslim client’s religious identity in the early stages of the therapeutic process is a way to enhance the therapeutic relationship, the therapeutic process, and the counselor’s multicultural competence and at the same time empower the client.

Counselors could examine their attitudes toward Muslims and their knowledge about Muslims and Islam and ask themselves, “What, if any, is the influence of my attitudes and knowledge about Muslims on my approach, problem conceptualization, and work with this population?” Muslims in the United States are a racially and ethnically diverse population that include converts and born Muslims from all over the world. Muslims in the United States are not only Arabs or Asians, as often perceived, but are also Europeans, Latinos, Africans, Native and African American–born Muslims, and converts. In fact, the majority of Muslims in the United States are African Americans (Gallup, 2009).

Islam is an integral part of daily life for Muslims, although Muslims differ in their adherence to Islamic practices and values. For example, a practicing Muslim woman may not accept a male counselor, and practicing Muslim spouses may expect marital counseling founded on Islamic values. It is important for counselors to distinguish between Muslim clients’ religious and cultural beliefs. For example, marriage between cousins is permissible in Islam and is a common practice among some Muslims, such as Arabs or Asians, but this practice is not only uncommon but culturally unacceptable among others, such as Bosnian Muslims. On the other hand, religious Muslim spouses, regardless of their ethnic background, may have similar matrimonial relationships founded on Islamic teaching. They may expect and benefit from marital counseling integrated with their religious view of marriage. Muslim spouses who adhere to religious practices to a lesser extent may have different views of the marital relationship based on cultural convictions common to their ethnic group.

If therapy occurs during Ramadan, a month of fasting from sunrise until sunset (no drinking and eating of anything), a counselor could make arrangements so the client could perform a prayer, or could offer a session in the morning, as the fast is arduous, especially during the long summer days. A client may ask to perform the prayer in the counselor’s office because intentionally missing one of five daily prayers is a major sin. Practicing Muslims would rather miss a counseling session than one of the mandatory prayers.

It is common for Muslims to invite others for iftar (a dinner right after sunset during the fasting month of Ramadan) at their home or at a mosque. Declining the invitation could negatively affect the therapeutic relationship. Although accepting the invitation could be challenging for a counselor of a different background, it could be a rewarding experience (especially if an iftar is served at a mosque) that would help the counselor understand the client’s values, lifestyle, and available community resources. If a dinner is served at a mosque, it is expected that men and women will sit separately and that proper attire will be worn, such as long sleeves, long skirt/pants, and a scarf for women and a shirt with sleeves and pants below the knees for men.

In Islamic practice, interactions between men and women are minimalized, and some Muslim clients may request and accept only a counselor of the same gender for individual counseling. The choice of counselor for marital or family counseling may be more flexible because another person, specifically a mahram (an unmarriageable man for that specific woman, such as her father, brother, or uncle), might be present during a session. Some Muslim clients, both men and women, may not shake hands with a person of the opposite gender. Others may accept a handshake but might think they have committed an inappropriate act and feel guilty. It is best if the counselor allows a Muslim client to choose whether or not to greet in this way.

Because of Islamic beliefs about lowering one’s gaze, some Muslim clients may not maintain eye contact with a counselor of the opposite gender. If the counselor maintains eye contact, the client might consider this inappropriate, and it could make the client uncomfortable.

For counselors who hope to reach Muslim clientele and reduce their underutilization of counseling services, a proactive and innovative approach is needed. Rather than waiting for Muslim clients to visit an office or an agency, a counselor could establish a collaborative relationship with local Imams and offer counseling services at a mosque. Liaison with local Imams is very important. Also, Imams could be invited as guest lecturers in classrooms and community mental health agencies. Counselors could offer support and consultation to Imams in their work because Imams are familiar with community dynamics and their job duties include counseling and advising community members. If there is more than one mosque in the greater Muslim community, I strongly recommend establishing working relationships with all local Imams, if possible, to better understand the differences and similarities among diverse Muslim populations.

In conclusion, it is important to consider that Muslims may lack trust in counselors of different religious backgrounds. To build trust and increase utilization of counseling services, counselors can use Islamic teaching as a resource when applicable, such as using examples from the Qur’an and Sunnah (Prophet Muhammed’s [pbuh] life) in marital counseling, and religious coping in both individual and marital counseling, to meet the needs of this population. Religion and religious coping are sources of resilience for many Muslims during stressful times in their lives. Counselors need to examine how their attitudes toward Muslims and their knowledge about them may affect their work with this diverse population. By becoming aware of Muslim religious beliefs and related daily activities, counselors can begin to explore how these might be relevant to counseling specific Muslim clients. Counselors need to work within the boundaries set by their clients’ beliefs and values, including religious beliefs and values, and be mindful of cultural and practicing variations among Muslims.

Conclusions

The multicultural and social justice orientation to counseling has many implications for rethinking what counselors consider to be appropriate therapeutic boundaries. The eight guest contributors to this chapter presented very diverse cultural perspectives, yet they identified a common theme in the need for flexibility in defining boundaries related to gift-giving, self-disclosure, social relationships with clients, and community involvement. Many, many additional cultural perspectives could have been included in this exploration of boundaries, which we think underscores the richness of the possibilities for improving counseling services to diverse client populations.

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